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Dans cet article, nous proposons, dans le cadre d’une recherche-action, une approche d’amélioration des processus hospitaliers basée sur l’identification des étranglements. L’objectif est de rationaliser les processus hospitaliers afin d’accélérer les flux et fournir des services de haute qualité aux moindres coûts. L’approche combine le Business Process Management et le Lean Management pour tirer profit de leurs forces respectives. En procédant d’une façon descendante, nous avons commencé par identifier et classer les processus du service d’urgences du CHU Charles Nicolle à Tunis, Tunisie. Ensuite, nous avons formalisé le processus de prise en charge des patients pour dresser une cartographie de la chaîne de valeur permettant d’identifier et de quantifier les activités sans valeur ajoutée, principalement les attentes et les déplacements inutiles. Cette cartographie a révélé deux principaux goulots ainsi que l’importance de la coordination et de la mise en place d’un système efficace d’information et d’aide à la décision. Un tel outil devrait permettre de décloisonner les différents services du CHU tout en permettant de synchroniser les différentes activités afin de le piloter d’une façon plus efficace.

The 5S-Kaizen-TQM is a step-by-step approach, originally implemented in the Japanese industry as a continuous improvement strategy.To underline the positive impact of its implementation in three pilot departments in Tunisia public hospital.The 5S-KAIZEN-TQM introduced into three clinical departments lasted 6 months from February 2021 to July 2021. Firstly, we organized seminar to introduce this approach and training sessions on 5S and Kaizen activities to each department staff members. To collect data, we conduct satisfaction surveys, face to face interviews, meetings, and brainstorming sessions. To present these data, checklists, Analytic Hierarchy Process (AHP), Ishikawa chart, Value stream mapping (VSM) charts and visual management techniques were adopted. Then, with the participation of the staff members, we implemented the two steps of this approach and evaluated their performance by the identification of indicators related to each step and to each Departement.The project had positive implications on employee and patient satisfaction. 5S step activities leaded to the reduction of the item research time and the releases of space. Improving the working environment increased staff satisfaction. Kaizen activities conducted to the reduction of process lead time and the error reductions which increased patient satisfaction.This project, first in Tunisia, was undertaken by Tunisian National Health Evaluation and Accreditation Agency (INEAS) and partners as part of the program for the research on organizational innovation in health. The fundings of this project can be disseminated and perpetuated the 5S-KAIZEN-TQM approach in the health sector in countrywide.

During the month of Ramadan, over one billion Muslims observe a water and food fast from sunrise to sunset. The practice of this religious duty causes marked changes in eating and sleeping habits. With the increasing incidence of cardiovascular (CV) risk factors, the number of patients with CV pathologies who wish to fast is increasing worldwide, and in Tunisia, which is ranked as a high CV risk country. If fasting has been shown to be beneficial for the improvement of some metabolic parameters, its practice in patients with CV pathology remains debated. The Tunisian Society of Cardiology and Cardiovascular Surgery (STCCCV) in consultation with the National Instance of Evaluation and Accreditation in Health (INEAS) has established this document in the form of a consensus after having analysed the literature with the aim of addressing these questions: -What is the impact of fasting in patients with CV pathologies? -How to stratify the risk of fasting according to CV pathology and comorbidities? -How to plan fasting in patients with CV diseases? -What are the hygienic and dietary measures to be recommended during fasting in patients with CV pathologies? -How to manage medication during the month of Ramadan in patients with CV diseases?

IntroductionHealth technology assessment (HTA) has become a critical support to health policy decision-making. The HTA evaluation process requires transparency, formalized processes, clear timelines, and standardization according to international best practice. Tunisia is establishing an HTA-based decision-making system through the National Authority for Accreditation and Assessment in Healthcare (INEAS) to ensure impartiality and fairness in decision-making, which is important for an emerging democracy. INEAS opted for a participatory approach in developing the national health economic guidelines to better engage healthcare sector stakeholders in the HTA process. We aimed to present the main phases of the process used to develop the Tunisian health economic guidelines, the methodological choices for pharmacoeconomic evaluations, and the methodological choices for budget impact analyses.MethodsThe different phases of developing the guidelines were listed and reported.ResultsThe guidelines were developed under a technical cooperation program of the World Health Organization and involved collaboration between the Institut national d’excellence en santé et en services sociaux (INESSS in Quebec, Canada) and INEAS. The first version of the guidelines was drafted following a review of international HTA guidelines and best practice reference books, taking into account the Tunisian healthcare system context. This first draft was discussed in a workshop with the main health system stakeholders and then peer reviewed by international experts. Based on the feedback from experts, a second version was prepared and published on the INEAS website for public consultation. The Union of Innovative Pharmaceutical Research Companies (SEPHIRE), the National Health Insurance Fund (CNAM), and healthcare professionals provided the majority of feedback. The comments provided by SEPHIRE were discussed during a second workshop. The guidelines were revised and updated based on the comments provided and the final version was published in November 2021.ConclusionsINEAS adopted a participatory approach for developing its economic guidelines, which enhanced engagement of the major health system stakeholders in the HTA implementation process in Tunisia.

IntroductionIn many low- and middle-income countries scarcity of local data on health outcomes and health-related quality of life (HRQoL) is a hindrance to conducting cost-effectiveness analyses. The Tunisian National Authority for Accreditation and Assessment in Healthcare (INEAS) developed a set of methodological guidelines to support pharmaceutical companies in the submission of health technology assessment (HTA) dossiers. The guidelines include INEAS’ methodological choices for pharmacoeconomic analysis, which take into consideration the specificities and constraints of the Tunisian context. We aimed to present the principal recommendations of the Tunisian guidelines for pharmacoeconomic studies, with a focus on patient-reported outcome and HRQoL measurement.MethodsThe INEAS pharmacoeconomic analysis guidelines were reviewed and the recommendations regarding outcome measurement and HRQoL were retrieved and reported.ResultsTo populate the economic model, INEAS recommends using the best available evidence. Health outcomes should be measured in terms of life-years gained and quality-adjusted life-years (QALYs); disability-adjusted life-years can be used but are not the preferred method. To estimate QALYs, INEAS favors the indirect measure of patient preferences with a validated measurement instrument. Alternatively, other measures of utility may be used, including those identified through a systematic review of the scientific literature and the publications of other HTA agencies. Justification and details of the source of the data must be provided. The utility values selected should be recent and representative of the Tunisian population, as far as possible. The guidelines refer to a set of generic preference-based HRQoL instruments, including the EuroQol five-dimensions (EQ5D), the Health Utilities Index Mark 2 (HUI2) and Mark 3 (HUI3), and the Short-Form Six-Dimension (SF-6D), but do not provide any explicit recommendations on their use.ConclusionsThe INEAS pharmacoeconomic analysis guidelines adhere to international best practices but provide more flexibility for overcoming the lack of local data. The INEAS economic guidelines constitutes a further milestone in the process of implementing HTA in Tunisia and in the Middle Eastern and African regions.

The quality assessment of the provided cares is an ongoing challenge for public healthcare organizations. According to a systemic overview, the performance evaluation of any system requires the identification as well as the evaluation of each of its main processes. However, addressing the performance of an emergency department is often limited to its mission of patient care.The objective of this work is to propose a tool that continually evaluates the performance of an emergency department within a teaching hospital by simultaneously considering its both vocations: (i) health care delivery to patients and (ii) skill training for learners.In line with the principles of continuous improvement drive andmanagement by objectives, appropriate performance indicators have been proposed for each of the two processes. In addition, a dashboard has been implemented to provide decision makers with a synthetic overview of the department performance measures.One of the major shortcomings of dashboards is the issue of data collection, input and updating. To overcome this shortcoming, it is recommended to integrate it into an information and decision-making support system that manages the entire emergency department.

IntroductionAs a new milestone in health technology assessment (HTA) implementation in Tunisia, L’Instance Nationale de l’Evaluation et de l’Accréditation en Santé (INEAS)—the Tunisian HTA body—published a set of methodological guidelines to support HTA dossier submission by the pharmaceutical industry. Including, ‘guide for submitting clinical data for an HTA at INEAS’, ‘methodological choices guide for pharmacoeconomic analysis at INEAS’, and ‘methodological choices guide for budget impact analysis at INEAS’. We aim to report the major methodological recommendations of the pharmacoeconomic analysis guideline.MethodsThe ‘methodological choices for pharmacoeconomic analysis at INEAS’ guideline was reviewed and the major recommendations were retrieved and reported.ResultsThe reference analysis required by INEAS is the cost-utility analysis systematically combined with a cost-effectiveness analysis (cost per life-year gained) from the public payers’ perspective. The choice of any other type of analysis must be duly justified. Comparators should include alternative treatments which are considered to be ‘the standard of care’ (i.e., interventions routinely used in Tunisia for the same indication) and in which public resources are invested. The time horizon should be sufficiently long to reflect all differences in costs and outcomes. Additionally, a discount rate of 5 percent per year is recommended. The best available evidence for efficacy, safety and quality of life is required. An indirect measure of patient preference, through a validated measurement instrument is preferred for utility calculation. Cost inputs should be identified from Tunisian sources. Health resource utilization should reflect the care pathway in Tunisia. INEAS favors the use of a recognized model. Uncertainty and impact of the input parameters on the results should be assessed and reported through probabilistic and deterministic sensitivity analyses. Model validation tests to assess face validity and internal validity should be performed, and a discussion of the methods used provided. Demonstration of external validity is required. Results should be presented in incremental cost-utility and cost-effectiveness ratios.ConclusionsThe recommendations of ‘methodological choices for pharmacoeconomic evaluation at INEAS’ is an important step to facilitate and harmonize pharmaceutical companies’ submissions and to enhance the use of these analyses in decision-making.

This paper investigates organizational reform in healthcare organizations and particularly in Emergency Departments (EDs). As EDs play a fundamental role in ensuring both the continuity and permanence of high-quality health care, their organization is still the subject of increasing attention from both researchers as well as professionals and remains a crucial field requiring continuous improvement. In this study, we are interested in a particular real case study focusing on the ED of a Tunisian public teaching hospital. Given the Tunisian context for health care system, the goal was first to explore the considered ED in-depth to examine carefully the actual organization and detect several problems on this issue. In this context, effective job descriptions were established to identify the strategic responsibilities and distinguish competencies of health care staff. Based on this organizational analysis, we were focused on the elaboration of an optimal organizational structure that is more appropriate to the investigated ED. Considering these successful initiatives in designing the overall organization structure, health care specialists would be able to create momentum for new progress in health care performance such as making much more effective schedules for their operational processes.

Industries have made claims on the effectiveness of a disinfection procedure in reducing COVID-19 transmission. This procedure is usually performed by automated dispersion of disinfectant on individuals when they go through a booth. This Health Technology Assessment (HTA) report is a systematic review that synthesizes the evidence on the efficacy and safety of using these booths and provides recommendations to the Ministry of Health to facilitate decision-making regarding the relevance of using this technology.A systematic literature review was performed using Pubmed, Web of Science, INAHTA and GIN databases, from inception to June 4, 2020. Three independent reviewers selected eligible studies then extracted and synthesized the evidence. The synthesis was submitted to a multidisciplinary group of experts to provide recommendations.Two scientific papers and a Malaysian HTA report were included in data synthesis. In light of the resources consulted, spraying disinfectants on humans in booths is not effective and can be toxic. Disinfectants are intended for use on surfaces, not on living tissue and spraying disinfectants on the outside of the body does not kill the virus inside an infected person's body. Furthermore, this procedure may increase the risk of neglecting other effective measures.It is recommended to prohibit the use of disinfection booths in all structures.

Diagnosis of SARS-CoV-2 infection is a major public health issue. In a context of limited diagnostic capacity with the reference technique (real-time RT-PCR), many manufacturers have developed rapid diagnostic tests (RDTs). Although very promising in theory, these tests have raised many questions. This article is a rapid review that synthesizes data regarding different types of available RDTs, their performance, their limits and their potential indications in Tunisia as proposed by a multidisciplinary group of experts.A literature review was carried out on the websites of international organizations, governmental bodies and on INAHTA database, completed by a search of relevant scientific articles up to 1 June 2020. The synthesis of the data was submitted to a panel of experts to propose recommendations for the Tunisian context.RDTs based on the detection of antigens and antibodies have sensitivity and specificity related issues. Few validation reports are published in the scientific literature. Pending more evidence on their performance and validity, several international organizations recommend their use only for research purposes. TDRs based on antibody detection are not appropriate for the early diagnosis of COVID-19. However, validated and specific tests could provide complementary diagnostic information to reference tests.Pending further evidence, the panel recommends the use of RDTs mainly for research purposes at the community level.

Despite the tremendous clinical advances, breast cancer remains one of the deadliest cancers for women around the world. This has led to a wide variety of awareness and screening programs in several countries, with often questioned real impacts. In this perspective, this multidisciplinary study was conducted to evaluate the effectiveness of the Tunisian national breast cancer screening campaign in 2019. The Data Envelopment Analysis (DEA) approach was used to measure the relative effectiveness of the governorates with respect to this campaign. Preliminary numerical experimentation reveals promising results and highlights venues for future studies.

Introduction: The Hajj pilgrimage in Mecca is an annual mass gathering event with high risk of infectious diseases.Method: In this short communication we try to check clinical evidence comforting pneumococcal vaccination to prevent pneumonia in elderly pilgrims to Mecca.Results and Discussion: Current medical researches focused on microorganism portage and pathogens responsible of epidemic infectious diseases. In this context, and since the epidemic meningitides declared among Mecca pilgrims in 1987, vaccination procedures were developed. However recommendations for prevention of respiratory tract infection, mostly faired when Influenza H1N1 or Middle East Coronavirus are suspected, are still under health professional expectations.Conclusion: Since many countries published clinical expert reports, we recommend an international clinical survey to provide evidence based practice of pneumococcal vaccination for elderly pilgrims to Mecca.

Resume Objectif Le prelevement d’organes humains en Tunisie reste en deca des besoins. Ceci est en partie du au refus des familles a ce que l’on preleve les organes de leurs proches en mort encephalique. Nous avons realise une enquete sur un echantillon representatif de la population de la capitale tunisienne (2,8 millions habitants) avec comme objectif de preciser, parmi les personnes refusant cette notion du don cadaverique, les determinants du refus pour individualiser des pistes d’action. Methodes Ce sondage d’opinion a ete effectue dans la region de Tunis entre le mois de mars 2006 et le mois de fevrier 2007. Les 16 questions de l’enquete repondaient a quatre themes principaux a savoir l’evaluation des connaissances, l’opinion et l’attitude du citoyen, la justification explicite du refus et les declarations avancees en cas de refus du don d’organes. Resultats 80,7 % des 902 individus sondes connaissaient la greffe d’organes en Tunisie. Une personne sur deux acceptait de donner ses organes apres la mort. Parmi le groupe d’enquetes refusant le don de leurs organes apres la mort, l’absence d’un plaidoyer clair a ete observee dans 55,3 % des cas. L’atteinte a l’integrite du corps apres la mort ainsi que l’obstruction religieuse etaient en tete de liste des determinants du refus avec respectivement une prevalence de 79,9 % et 63,1 %. Conclusion La quete dans la relation corps et spiritualite et l’individualisme comportemental sont les deux explications de l’ampleur de ce phenomene de refus du don d’organes a Tunis.

It would be interesting to the emergency doctor to have at his disposal a helpful diagnostic tool like brain natriuretic peptide (BNP). Such assay is simple, available and reliable.To report our experience on the role of BNP in the etiological diagnosis of acute dyspnea (AD) in emergency room (ER) and to assess the cost-effectiveness ratio of such diagnosis strategy.A prospective study conducted in the ER of Rabta university teaching hospital of Tunis, from March 1st to June 20th 2010, involving 30 consecutive patients presenting to the emergency for AD. All patients underwent echocardiography in their acute phase and benefited from the dosage of BNP during the first 4 hours. The echocardiography parameters were collected by a single operator who was unaware of the results of the BNP dosage.The mean age of patients was 72.8years with a sex ratio of 1.5. AD was of orthopnea type in 9 cases and stage III NYHA dyspnea in the other patients. Clinical and radiological signs of left heart failure were noted in 30% of cases. Ultrasound data have objectified systolic dysfunction in 4 cases, diastolic in 3 cases and systolic plus diastolic in 10 cases. The BNP levels were below 100 pg/ml in 10 cases with pulmonary origin of the AD. A BNP level between 100 and 400 pg/ml was noted in 3 cases. In our study, the clinical probability of AHF prior to performing the test was estimated at 53% and estimated at 100% after the BNP assay. The BNP assay has reduced the length of stay in the emergency department 4 to 5 days and saved nearly 50% of the cost of care per patient.The BNP assay, has allowed us to confirm the AHF all cases. Given the prognostic value and economic benefit of this test we recommend its use in ER of our country.

Background The mild head injury is a mild traumatic pathology in most cases and the role of emergencies often comes down to an early lesion assessment, analgesic treatment and practice of a brain scan. The follow up is assured by the neurology departments and no feedback is communicated to emergencies and thus no relationship between the original picture and the prognosis can be established. The aim of our study is to evaluate the prognosis of mild head injury after one month based on initial data. Methods Descriptive prospective study of the clinical and evolutionary characteristics of mTBI isolated over a three months period (October-December 2009). Results We collected 200 cases of mTBI. The average age of patients was 38.9 years with a sex ratio of 1.78. The initial loss of consciousness was reported in 95 patients (47.5%) and was predictive of the presence of intracranial lesions (p = 0.02). Follow up has been done in 84.5% of cases. CT scan was performed in 50.5% and allowed to reveal traumatic defects in 16.8% of cases. The existence of an epistaxis, agitation or periorbital hematoma was correlated with the existence of traumatic injuries to the scanner (p Conclusions The initial loss of consciousness, the initial GCS, evaluating the severity of the accident and the patient’s condition are predictors of the existence of intracranial lesions indicating brain scan. These factors with brain damage, Masters Score and ISS are prognostic factors which are correlated with the appearance of post concussion syndrome. Early psychological treatment is necessary.

In Tunisia organ donation stays very low. This is in part due to family's opposition in brain death situation. We realized a survey on a representative group of the Tunis's population (2.8 millions citizens) in the aim to clarify, among persons refusing organ donation, the prevalence of refusals determiners to individualize actions.This survey was made in the region of Tunis between March 2006 and February 2007. The 16 questions of the survey were classified in four subjects: organ donation knowledge, opinion and attitude of the citizen, explicit justification and statements advanced in case of organ's donation refusal.80.7% of citizens sounded are informed with the possibility of organ transplant in Tunisia. Only 50% of persons agree to accept organ donation after dying. Among the group refusing organ donation after dying, the absence of an understandable argument is recorded in 55.3% of cases. The violation on body integrity after death as well as religious obstruction are at the head of list of statements advanced in case of organ's donation refusal with respectively 79,9% and 63.1%.Relation researched between bodies and spirituality and individualism are the two explanations of this phenomenon of refusal of organ donation in Tunisia.