Nurses
• Registered Nurses - real nurses
• LPN - licensed practical nurses
• Nurse Practitioners
• non-licensed caregivers
Nurse-Patient Relationship
• Nurses are independently licensed
• Nurses have an independent duty to patients
• Nurses exer...
Independent Nurse Practice
• Nurses may open an office and do wound
care and nutrition advise
• Nurses may not open an off...
Nurses in Institutions
• Nurses in hospitals and clinics are generally
employees of the institution
• The institution is g...
Nurse-Physician Relationship
• In most settings, nurses are absolutely
subservient to doctors
• A nurse may refuse an orde...
Nurse Extenders
• lower level care providers
• medical assistants, surgery technicians, lab
technicians
• on the job train...
Nurse Extenders in Institutions
• need to be carefully screened
• need to be carefully supervised
• institution has all th...
Other Providers
• Many other health care professionals
• Doctors
– physicians, psychologists, dentists
– independent – som...
Administrators
• great responsibility - little authority when it
comes to patient care
• laws forbid corporate practice of...
STRUCTURE OF HEALTH
SYSTEMS
20 February 2009
WHAT IS HEALTH ?
• A STATE OF COMPLETE PHYSICAL,
MENTALAND SOCIAL WELL-BEING,
NOT MERELY THE ABSENCE OF
DISEASE
• WORLD HE...
WHAT IS HEALTHCARE ?
• HEALTH CARE IS THE TOTAL
SOCIETAL EFFORT FOCUSED ON
PERSUING HEALTH
• MAY ACT ON INDIVIDUALS OR THE...
PUBLIC HEALTH VS
PERSONAL HEALTH
• PUBLIC HEALTH - TO IMPROVE THE
HEALTH OF A POPULATION
• PERSONAL HEALTH - TO IMPROVE
TH...
US PUBLIC HEALTH SYSTEM
• Local System – very political
• Governed by Boards of Health
• Health Officer/Director
HEALTH DEPARTMENTS
• Environmental Management
– Vectors
– Water quality
– nuisances
• Disease Control
– Clinics
– Epidemio...
PREVENTION
• PRIMARY - PREVENTION OF DISEASE
• SECONDARY - PREVENTION OF
CONSEQUENCES OF DISEASE
• TERTIARY - PREVENTION O...
HEALTHCARE ORGANIZATIONS
• Hospitals
• Residential Care
• Home Services
• Physicians’ Offices – 37%
• Dentists’ Offices – ...
INTEGRATED
ORGANIZATIONS
• HOSPITALS, PHYSICIANS, INSURERS,
AND PURCHASERS FORM
VERTICALLYAND HORIZONTALLY
INTEGRATED ORGA...
HORIZONTAL INTEGRATION
• LINKING ORGANIZATIONS OF THE
SAME TYPE TO INCREASE MARKET
SHARE
• MEDICAL EXAMPLE
– BUYING ALL TH...
VERTICAL INTEGRATION
• LINKING ORGANIZATIONS SO THAT
SUCCEDING TRANSACTIONS STAY
WITHIN THE SYSTEM
• MEDICAL EXAMPLE
– OCH...
HIGHLY INTEGRATED
HEALTH SYSTEM
• VERTICAL INTEGRATION AND AN
INSURANCE CONTRACT
• BIG MOVE TOWARD THIS IN THE
1980s AND 1...
TRIAD OF GOVERNANCE
• Governing Body
• CEO
• Professional Staff Organization
Hospital Medical Staff
• Bylaws are the structure
– Not like corporate bylaws
• Licensed Independent Practitioners
– Their...
Practitioner Relationship with the
Hospital
• 1) simple privileges
• 2) contractor – radiology
• 3) employee – medical dir...
Credentialing
• Prove training and experience
• National Practitioner Data Bank
• Major liability for the hospital
Impaired Practitioners
• 8 to 15% of physicians
• 10% of nurses
• Required reporting
• Formal rehabilitation programs
• Us...
Management Skills
• There is special training for healthcare
administration
• Getting an MD or a BSN does not make you
too...
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  1. 1. Nurses • Registered Nurses - real nurses • LPN - licensed practical nurses • Nurse Practitioners • non-licensed caregivers
  2. 2. Nurse-Patient Relationship • Nurses are independently licensed • Nurses have an independent duty to patients • Nurses exercise independent judgment
  3. 3. Independent Nurse Practice • Nurses may open an office and do wound care and nutrition advise • Nurses may not open an office and practice medicine even if they are nurse practitioners • Nurses may not be hired by a hospital to set up a medical practice
  4. 4. Nurses in Institutions • Nurses in hospitals and clinics are generally employees of the institution • The institution is generally responsible and liable for what they do. • If a physician hires a nurse, the physician takes on these responsibilities
  5. 5. Nurse-Physician Relationship • In most settings, nurses are absolutely subservient to doctors • A nurse may refuse an order but may not change an order • Nurses may be protected from bad orders by the practice acts or the rules of the hospital
  6. 6. Nurse Extenders • lower level care providers • medical assistants, surgery technicians, lab technicians • on the job training vs certification
  7. 7. Nurse Extenders in Institutions • need to be carefully screened • need to be carefully supervised • institution has all the responsibility • cannot rely on the license or certification
  8. 8. Other Providers • Many other health care professionals • Doctors – physicians, psychologists, dentists – independent – some with limitations • Technicians – x-ray, laboratory, pharmacy – legally and administratively similar to nurses
  9. 9. Administrators • great responsibility - little authority when it comes to patient care • laws forbid corporate practice of medicine • need good contracts and institutional rules so they can control what goes on • some states license or register administrators
  10. 10. STRUCTURE OF HEALTH SYSTEMS 20 February 2009
  11. 11. WHAT IS HEALTH ? • A STATE OF COMPLETE PHYSICAL, MENTALAND SOCIAL WELL-BEING, NOT MERELY THE ABSENCE OF DISEASE • WORLD HEALTH ORGANIZATION
  12. 12. WHAT IS HEALTHCARE ? • HEALTH CARE IS THE TOTAL SOCIETAL EFFORT FOCUSED ON PERSUING HEALTH • MAY ACT ON INDIVIDUALS OR THE ENVIRONMENT • EXPANDED GREATLY OVER THE LAST 40 YEARS
  13. 13. PUBLIC HEALTH VS PERSONAL HEALTH • PUBLIC HEALTH - TO IMPROVE THE HEALTH OF A POPULATION • PERSONAL HEALTH - TO IMPROVE THE HEALTH OF THE INDIVIDUAL
  14. 14. US PUBLIC HEALTH SYSTEM • Local System – very political • Governed by Boards of Health • Health Officer/Director
  15. 15. HEALTH DEPARTMENTS • Environmental Management – Vectors – Water quality – nuisances • Disease Control – Clinics – Epidemiology • Personal Health Services
  16. 16. PREVENTION • PRIMARY - PREVENTION OF DISEASE • SECONDARY - PREVENTION OF CONSEQUENCES OF DISEASE • TERTIARY - PREVENTION OF DEATH OR DISABILITY
  17. 17. HEALTHCARE ORGANIZATIONS • Hospitals • Residential Care • Home Services • Physicians’ Offices – 37% • Dentists’ Offices – 20% • Other Practitioners Offices • Ambulatory Care Centers • Other Outpatient Services • Lab, Xray, & Other Diagnostics • Day Care
  18. 18. INTEGRATED ORGANIZATIONS • HOSPITALS, PHYSICIANS, INSURERS, AND PURCHASERS FORM VERTICALLYAND HORIZONTALLY INTEGRATED ORGANIZATIONS • IN OTHER CONTEXTS THESE ARE CALLED MONOPOLIES
  19. 19. HORIZONTAL INTEGRATION • LINKING ORGANIZATIONS OF THE SAME TYPE TO INCREASE MARKET SHARE • MEDICAL EXAMPLE – BUYING ALL THE NURSING HOMES • MONOPOLY EXAMPLE – AT&T, Cox Cable
  20. 20. VERTICAL INTEGRATION • LINKING ORGANIZATIONS SO THAT SUCCEDING TRANSACTIONS STAY WITHIN THE SYSTEM • MEDICAL EXAMPLE – OCHSNER CLINIC • MONOPOLY EXAMPLE – STANDARD OIL
  21. 21. HIGHLY INTEGRATED HEALTH SYSTEM • VERTICAL INTEGRATION AND AN INSURANCE CONTRACT • BIG MOVE TOWARD THIS IN THE 1980s AND 1990s • TREND IS NOW AWAY FROM VERTICAL INTEGRATION
  22. 22. TRIAD OF GOVERNANCE • Governing Body • CEO • Professional Staff Organization
  23. 23. Hospital Medical Staff • Bylaws are the structure – Not like corporate bylaws • Licensed Independent Practitioners – Their contract with the hospital
  24. 24. Practitioner Relationship with the Hospital • 1) simple privileges • 2) contractor – radiology • 3) employee – medical director • 4) employee/learner – residents • 5) extenders – any of the above
  25. 25. Credentialing • Prove training and experience • National Practitioner Data Bank • Major liability for the hospital
  26. 26. Impaired Practitioners • 8 to 15% of physicians • 10% of nurses • Required reporting • Formal rehabilitation programs • Used to be handled by the medical staff • Now the hospital’s problem
  27. 27. Management Skills • There is special training for healthcare administration • Getting an MD or a BSN does not make you too stupid to learn this

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