Hospitalservicesmanagement 120305100013-phpapp01


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Hospitalservicesmanagement 120305100013-phpapp01

  1. 1. Hospital Services and Management Nawanan Theera-Ampornpunt, MD, PhD Faculty of Medicine Ramathibodi Hospital, Mahidol University, Thailand Modified from slides of Assoc.Prof. Artit Ungkanont Parts of this material were based on materials developed by Johns Hopkins University, funded by the Office of the National Coordinator for Health Information Technology, U.S. Department of Health and Human Services under Award Number IU24OC000013 (Health IT Workforce Curriculum v.2.0, Component 7/Units 2-3).
  2. 2. A Bit About Myself 2003 M.D. (Ramathibodi) 2009 M.S. in Health Informatics (U of MN) 2011 Ph.D. in Health Informatics (U of MN) Medical Systems Analyst Health Informatics Division Faculty of Medicine Ramathibodi Hospital Mahidol University Research interests: • Health IT applications in clinical settings (including EHRs) • Health IT “adoption” • Health informatics education
  3. 3. Outline • Overview of the healthcare system • Hospitals as a key component • Nature of hospital services • Contrast with ambulatory & emergency settings • Management of hospital operations • Needs for health IT in hospitals • Conclusion
  4. 4. The Healthcare System Hospital A Hospital B Clinic C Government Lab Patient at Home
  5. 5. Stakeholders in Health Care Patients Providers Policy- Makers Public Payers • High bargaining power • Want to pay less money for more quality • Want to deliver the best outcomes to patients with limited resources • Needs to satisfy many “bosses” • Want data for policy-making and management • Limited budget • Often face bureaucracies • Highly political • Concerns about resource allocation & community’s well-being, but not necessarily individual patients • Want a high-quality care and satisfactory service experience for an acceptable cost
  6. 6. Providers • Provide health care services to patients • Hire or employ health care professionals, including physicians, nurses, pharmacists, etc. • Receive payment from patients or third-party payers – National Health Security Office – Social Security Office – Comptroller-General Department – Private insurance companies
  7. 7. Providers in Thailand’s Various Settings • Ambulatory Setting – Private clinics (sometimes called physician’s offices) – Outpatient departments of hospitals – Private pharmacies – Dental clinics – MOPH’s community health centers • Currently called “health promotion hospitals” • They are not really hospitals!! Just a political marketing tool!
  8. 8. Providers in Thailand’s Various Settings • Emergency Setting – Emergency rooms of hospitals – Ambulances and pre-hospital care – Incident management and command
  9. 9. Providers in Thailand’s Various Settings • Inpatient Setting – Inpatient wards for • Acute care hospitals • Nursing homes (for the elderly and chronic patients) • Hospice (for the terminally ills) – Special cases • Delivery room • Patients being observed in emergency rooms • Short stay services
  10. 10. Transitions Between Settings Healthy Ambulatory (Outpatient) Care Emergency Care Hospital Inpatient Care
  11. 11. Hospital Services in Thailand Ambulatory (Outpatient) Care Emergency Care Inpatient Care Surgery (Operating Rooms)
  12. 12. Why We Need To Hospitalize (Admit) Patients • Serious illness or injury • Need to monitor patient status closely • Need to observe progression of illness • Need to administer intravenous drugs or fluids • Need extensive/ongoing investigations • Need to observe response to treatment and adjust plans, or because of potential treatment side effects • Before and after major surgery or procedures • Etc.
  13. 13. Importance of Hospital Services • Sophisticated capabilities & technologies – Labs – X-rays – Surgeries – Other treatments and technologies • Integrated services by multiple specialties • Ability to provide level of care needed by each patient – General wards for different specialties (medicine, surgery, OB-GYN, pediatrics, orthopedics, eye, ENT, etc.) – Intensive Care Units (ICUs), Cardiac Care Units (CCU) – Public (shared) wards vs. private rooms • Referral systems of increasing capabilities
  14. 14. Class Discussion #1 • What are some different types of hospitals you can think of? • What characteristics do you think make these hospitals different?
  15. 15. Types of Hospitals in Thailand Hospital Category Number of Hospitals Percentage of All Hospitals District hospitals (MOPH) 737 56.4% General hospitals (MOPH) 68 5.2% Regional hospitals (MOPH) 26 2.0% Other hospitals under MOPH* 50 3.8% Other public hospitals outside MOPH† 111 8.5% Private hospitals 315 24.1% Total 1307 100.0% *Including general and specialty hospitals under other departments within the Ministry of Public Health. †Including university hospitals, military hospitals, autonomous public hospitals, prison hospitals, hospitals of state enterprises, and public hospitals under local governments. MOPH = Ministry of Public Health Source: Bureau of Policy and Strategy, Ministry of Public Health (November 2010).
  16. 16. Hospital Characteristics • Geographic location – Province – Urban/rural • Size – Bed size – Number of employees – Patient volume
  17. 17. Hospital Characteristics • Level of services – Primary care – Secondary care – Tertiary care – Supertertiary care • Ownership – Public/private status – Parent organization – Being in a multi-hospital system
  18. 18. Hospital Characteristics • Teaching status – Non-teaching hospitals – Teaching hospitals • Budget • Service capabilities – Medical technologies available – Medical specialties available • etc.
  19. 19. Class Discussion #2 • How many of you have had an experience being admitted to a hospital or had a relative who was admitted? • Can you share some non-confidential parts of the story? – Describe what happened. – What did the providers do to you/your relative in the hospital? – How was the experience (your feeling of the experience)?
  20. 20. An Overview of Hospital Services Services Information From Dr. Artit Ungkanont’s slide
  21. 21. Nature of Emergency Care Source:
  22. 22. Nature of Ambulatory Care
  23. 23. Ambulatory Processes • Check-in – Verify Appointment; Update Info; Pull Medical Record • Move to exam room – Vital Signs; Review Reason for Visit; Document – Examination; Discussion of Findings; Plan; Order; Documents • Check-out – Schedule appointment – Payment • After the fact – Complete Documentation/Dictate – Code Visit & File Insurance Claim Health IT Workforce Curriculum Version 3.0/Spring 2012 Working with Health IT Systems, Under the Hood, Lecture a
  24. 24. A Typical Process for Outpatient Care Registration (New patients only) OPD Check-in Verify appointment, insurance eligibility, pull medical records OPD nurse performs brief history taking, vital signs measurement Doctor takes history and physical examination Doctor writes documentation Doctor orders investigations (lab, x- rays, etc.) Doctor reviews results Doctor writes prescription OPD Check-out OPD nurse reviews order, educates patient, makes appointment (if any) Patient makes payment Patient receives medications and go home
  25. 25. Nature of Inpatient Care
  26. 26. Nature of Inpatient Care
  27. 27. A Typical Process for Inpatient Care Entry Point Patient registration Admission processing (verify admission paperwork, insurance eligibility) Patient stays in a ward Doctor takes history & physical examination in an admission note Doctor writes order for investigations (lab, x- rays, etc.) and treatment Nurse reviews and processes orders Doctor reviews investigation results Nurse measures vital signs every 6 hours or as ordered, writes nurse’s notes Discharge planning Patient makes payment, receives home medications & education, discharged Hospital makes claims and receives reimbursements
  28. 28. Inpatient Processes 1. Register 2. Review Patient Info 3. Talk, Observe, Examine 4. Document *H&P, PMH, Signs/Symptoms, etc. 5. Take Actions “Orders” *Meds, Labs, Procedures, Consults, Admit, Next Appt. 6. Discharge 7. Patient Education (could occur anywhere in the process) 8. Health Data Reporting 9. Link to Reimbursement Health IT Workforce Curriculum Version 3.0/Spring 2012 Working with Health IT Systems, Under the Hood, Lecture a
  29. 29. Entry Point for Inpatient Admissions • From outpatient visits • From emergency room • Referred from another facility • Scheduled inpatient appointment – Pre-operative (before surgery) admissions – Chemotherapy – Other procedures that require hospitalization • Operating room – Post-operative (after surgery) care – One-day surgery with unexpected complications requiring admission
  30. 30. Routine Ward Work for Physicians • Morning Ward Rounds – Check patient’s illness progression, changes from previous rounds, lab/x-ray results, response to treatment – Plan next steps • Ordering investigations and treatments – Lab tests – X-rays – Medications and IV fluids – Surgeries & bed-side procedures – Nursing procedures – Diet – Patient activity • (Optional) Afternoon Ward Rounds • Progress notes & other documentation • Providing treatments during the day as necessary (e.g. CPR)
  31. 31. Routine Ward Work for Nurses • Typically an 8-hour shift • Observe and document patient status, illness progression, and changes • Measure routine vital signs and intake/output • Review and process doctor’s orders • If patient condition is serious or urgent, inform physicians • Perform nursing interventions as ordered • Coordinate with other departments and staff • Assist physicians in bed-side procedures • Documentation – Nurse’s notes – Medication administration records (MARs) – Vital sign – Kardex (for within-shift communications and between-shift hand-over) – Other administrative documents
  32. 32. Discharge Status • Discharged home with approval • Left against medical advice • Escape • Referred to another facility • Expired (Dead)
  33. 33. What Is Different? • Access to systems & data • Challenges of geography • Patient Load • Episode of Care • Facilities and technologies available • Level of monitoring and control of environment • Coordination, Communication, Consultation Health IT Workforce Curriculum Version 3.0/Spring 2012 Modified from “Working with Health IT Systems, Under the Hood, Lecture a”
  34. 34. Inpatient vs. Ambulatory Processes: Comparing and Contrasting How do they differ? – Inpatient 4 phases • Initial evaluation • Ongoing Management • Pre-discharge • Discharge – Ambulatory • Episodic • Coordination across providers and locations • Monitoring/treatment chronic & acute Health IT Workforce Curriculum Version 3.0/Spring 2012 Working with Health IT Systems, Under the Hood, Lecture a
  35. 35. Managing Hospital Operations • Typical Organizational Structure – Hospital Director as top executive – Various clinical departments depending on medical specialties and services available – Nursing Department • Important Administrative Departments – Director’s Office – Quality improvement, Risk management – IT – Finance, Human Resource (HR), Procurement – Academic/Education/Research
  36. 36. Supporting Care Processes with HIT • Facilitate filtering, organizing, & access • Thoroughness and currency imperative • Reviewing & Documenting • Planning • “Doing” – ordering • Educating Health IT Workforce Curriculum Version 3.0/Spring 2012 Working with Health IT Systems, Under the Hood, Lecture a
  37. 37. Supporting Care Processes with HIT • Communicating – High risk, high stress – Teams – working independently but with constant information exchange – Moving patients, moving providers, rapidly changing situations Health IT Workforce Curriculum Version 3.0/Spring 2012 Working with Health IT Systems, Under the Hood, Lecture a
  38. 38. IT Management in Hospitals • Front Office – Hospital Information Systems (or Clinical Information Systems) • Back Office – Management Information Systems – Including Enterprise Resource Planning (ERP) systems – Research and Education – Office Automation Tools • Data Warehouse, Data Analysis & Reporting • IT Infrastructure – Systems & Network Administration, including Security – Web Sites
  39. 39. Workflow Hospital Information System Master Patient Index (MPI) ADT Scheduling Order Pharmacy IS Operation Theatre Billing Clinical Notes LIS RIS PACS CCIS Medical Records Portals Modified from Dr. Artit Ungkanont’s slide
  40. 40. HIT Systems (Inpatient) Clinical Decision Support: “Any system designed to improve clinical decision making related to diagnostic or therapeutic processes of care.” From Dr. Artit Ungkanont’s slide
  41. 41. Care Processes: HIT Support • Registration – Admission, Discharge Transfer Systems (ADT) – Bed Management Systems (BMS) – Unique Identifier – i.e. Hospital Number (HN), sometimes called Medical Record Number (MRN) Health IT Workforce Curriculum Version 3.0/Spring 2012 Working with Health IT Systems, Under the Hood, Lecture b
  42. 42. Care Processes: HIT Support • Reviewing Patient Information – Retrieve patient record • Verifying demographics, etc. • Past medical history, etc. • Talking, Observing, Examining Health IT Workforce Curriculum Version 3.0/Spring 2012 Working with Health IT Systems, Under the Hood, Lecture b
  43. 43. Care Processes: HIT Support Documentation – Copious • Pick lists, Voice Recognition, Structured Notes, Integrated Records, Patient-Centered, Kiosks, PHRs … – Knowledge Resources & Decision Support Health IT Workforce Curriculum Version 3.0/Spring 2012 Working with Health IT Systems, Under the Hood, Lecture b
  44. 44. Care Processes: HIT Support Taking Action Performing/Ordering/Reviewing – CPOE – Computerized Prescriber Order Entry • E-prescribing, Consults, Treatments, Diets, Labs, Tests… – Guideline-based Care Health IT Workforce Curriculum Version 3.0/Spring 2012 Modified from Working with Health IT Systems, Under the Hood, Lecture b
  45. 45. Computerized Physician Order Entry (CPOE)
  46. 46. Care Processes: HIT Support • Pre-Discharge/Discharge – Ties into ADT, bed management, discharge planning … • Education Health IT Workforce Curriculum Version 3.0/Spring 2012 Working with Health IT Systems, Under the Hood, Lecture b
  47. 47. Care Processes: HIT Support • Reporting & Reimbursement – External (Disease Control & Prevention, Immunization Registries, Payers for reimbursement, etc.) & Internal (Practice Improvement, Trending, etc.) – $$$ Health IT Workforce Curriculum Version 3.0/Spring 2012 Working with Health IT Systems, Under the Hood, Lecture b
  48. 48. Summary • Hospitals are an important setting in health care • Nature and work processes in the inpatient, outpatient, and emergency settings are quite different • These settings have some common needs for health IT, but each also has unique needs • Hospitals are just one part of the whole healthcare system Health IT Workforce Curriculum Version 3.0/Spring 2012 Working with Health IT Systems Under the Hood Lecture b
  49. 49. Healthcare System: The Big Picture Hospital A Hospital B Clinic C Government Lab Patient at Home
  50. 50. QUESTIONS?