2. INTRODUCTION
• Successful case management relies on
critical pathway to guide care
• Critical pathway refers to the expected
outcomes and care strategies developed
by collaborative practice team
Page 2
3. HOW TO DEFINE..
• Critical paths are guides that outline the
critical or key events expected to happen
each day of patient’s hospitalization
-Cohen & Cesta,2001
Page 3
4. HOW TO DEFINE..(2)
• Critical pathways are one method of
planning, assessing, implementing and
evaluating the cost- effectiveness of
patient care
Page 4
5. HOW TO DEFINE..(3)
• A series of methods and instruments to
allign member of the interdisciplinary and
interprofessionally team for the care of the
pre defined patient population in order to
realize an efficient, patient centered, coordinated program of care
-Sermeus &
Vanhaecht,2002
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7. WHAT ARE ITS FEATURES..
•
•
•
•
•
•
Predetermined course of progress
Variance analysis
Fiscal planning
Directing
Orientation
Identifies outcome
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8. WHAT DOES IT CONTAINS..
•
•
•
•
Specific medical diagnosis
The expected length of stay
Patient identification data
Appropriate time frames (in days, hours,
minutes or visits) for intervention
• Patient outcomes
• Interventions presented in modality
groups ( medications, nursing activity & so on)
• Nursing diagnosis
Page 8
9. What it is actually….
• Clinical tools that organize, sequence and time
the major interventions of the nursing staff,
physicians, for a particular case type, condition,
diagnostic category or nursing diagnosis
• Describe an institutions collective standard of
practice, clinical budget
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10. What it is actually….
• Provides direction and predictability to
patient care and to caregivers interacting
in that case
• Shows something that must occur in the
sequence before one may proceed.
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11. COMPONENTS
• Clinical Pathways have four main components
(Hill, 1994, Hill 1998):
1. a timeline
2. the categories of care or activities and their
interventions
3. intermediate and long term outcome criteria
4. and the variance record
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12. How to develop critical pathway
Professional involved….
• Physician
• Nurse manager
• Staff nurse
• Social worker
• Dietician
• Occupational therapist
• pharmacist
Page 12
13. How to develop critical pathway
• Retrospective chart review or concurrent
chart review
• identify costs associated with the
treatment
• Pathway development teams are
organized to develop the tool
Page 13
14. How to develop critical pathway
• Patient care expectations and critical events are
identified for incorporation into the path
• Small groups within the development to refine
the elements of the path
Page 14
15. How to develop critical pathway
• Newly developed tools can be tested on
previously admitted patient
• Implementation with collaboration with
other professionals
Page 15
16. Critical pathway analysis
• Analyze the effectiveness
• Variance analysis
Positive variance
Negative variance
• Consult with other professionals
• Make change accordingly
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17. What is your role as Nurse
manager
•
•
•
•
•
Assess quality improvement
Effective planning
Evaluate quality
Interdepartmental Communication
Educating the staff of other departments about
the pathway role and responsibilities.
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18. What is your role as staff Nurse
•
•
•
•
Provides patient care
Follow critical pathway
Inform any deviance
Collaborate with other professionals
Page 18
19. Its advantages are……
• Provides standardizing medical care for
patients with similar diagnosis
• Use resources appropriate to the care
needed
• Reduce cost
• Reduce length of stay
• Improve the quality of care
• Change practice pattern to increase
efficiency
Page 19
20. Its advantages are…
• Improves care outcomes
• Use multiple disciplines and services
efficiently
• Sense of satisfaction
• Can support continuity and co-ordination
of care across different clinical disciplines
and sectors
Page 20
21. Its advantages are…
• Support the introduction of evidence-based
medicine and use of clinical guidelines
• Support clinical effectiveness, risk management
and clinical audit
• Improve
multidisciplinary
communication,
teamwork and care planning
Page 21
22. Its disadvantages are…
•
•
•
•
Differences between unique patients
One more paper work
Overburdened with administrative cost
Problems of introduction of new
technology
Page 22
23. Its disadvantages are…
• Require
commitment
from
staff
and
establishment of an adequate organizational
structure
• May take time to be accepted in the workplace
• Need to ensure variance and outcomes are
properly recorded, audited and acted upon.
Page 23
25. INTRODUTION
• Health care reform is a general rubric
used for discussing major health policy
creation or changes for the most part,
governmental policy that affects health
care delivery in a given place
Page 25
26. Introduction
• Despite various development plans, lack
of or inadequate basic infrastructure, both
social and physical, continues to remain a
major constraint to progress in many parts
of our country
Page 26
27. Definition
• Health care Reform is defined as a
sustained, purposeful change to improve
the efficiency, equity and effectiveness of
the health sector’
-(Berman 1995).
Page 27
28. AIMS
• Broader the population that receives
health care coverage
• Improve the access to health care
specialists
• Improve the quality of health care
• Decrease the cost of health care
Page 28
29. Reform strategies
• alternative financing (user-fees, health insurance,
community financing, private sector investment)
• institutional management (autonomy to hospitals,
monitoring and management by local government
agencies, contracting)
• public sector reforms (civil service reforms, capacity
building, productivity improvement); and
• collaboration with the private sector (public/private
partnerships, joint ventures)
Page 29
30. A.N.A PROPOSA L FOR
HEALTH CARE REFORM
• Health care delivery system restructuring
• Universally available standard health care
package
• Phase in of services, initial emphasis on
pregnancy and children
• Changes to reflect changing national
demographics
Page 30
31. A.N.A PROPOSA L FOR
HEALTH CARE REFORM
•
•
•
•
•
Long term care coverage
Insurance reform
System review and evaluation
Case managed health care
Decreased health care costs.
Page 31
33. THE NETHERLANDS
• Health care insurance based on risk equalization
• compulsory insurance package is available to all
citizens at affordable cost without the need for
the issued to be accessed for risk
• Health insurers are now willing to take on high
risk individuals because they receive
compensation for the higher risks
Page 33
34. RUSSIA
• Compulsory medical insurance with privately
owned providers in addition to state run
institutions
• Health care reforms in 2011 allocate more than
300 billion rubles to improve health care in
country
• Medical insurance tax paid by companies for
compulsory medical insurance will increase from
current 3.1% to 5.1% from 2011
Page 34
35. TAIWAN
• Taiwan changed the health care system
in1995 to National Health Insurance model
• As a result 40% who had been previously
uninsured are now covered
• 72.5% are happy about it, but they are
unhappy about the cost of premium ($20/
month)
Page 35
36. UNITED KINGDOM
• Private sector health care is quiet small (15%)
• Focus is on prevention of ill health
• Baby formula milk fortified with vitamins and
minerals to improve the health of the children
• Measles, mumps & chicken pox were mostly
eradicated with national programs of vaccination
Page 36
37. UNITED STATES
• 17% of GDP is spent on health care, but 77% of
Americans have at least one chronic disease
• U.S ranks 31st in life expectancy and 40th in child
mortality
• Health care system ranks 37th among nations
• Therefore the reforms are concentrating on
reducing the cost of health care rather than on
improving outcomes
Page 37
39. UNITED STATES
• The mixed public private health care system in
U.S is the most expensive in the world
• Greater portion of GDP is spent on it
• According to 2008 common wealth fund report,
U.S ranks last in the quality of health care
among developed countries
• WHO,2000 ranked U.S health care system 37th in
overall performance & 72th by overall level of
health
Page 39
40. UNITED STATES…
• U.S Government provides health care to
just over 25% of its citizens through
various agencies but otherwise does not
employ a system
• Health care is generally centered around
regulated private insurance methods
Page 40
44. INDIAN SCENERIO
• 37% of Indian population is undernourished
• 55% have a diet which is calorie sufficient but
nutrient deficient
• 8% is over nourished
• Total imbalance of nutrition leads to anemia, TB
and many disease which increases the disease
burden
Page 44
45. INDIAN SCENERIO…
• Arthritis. HT, DM, CVD, cancer and elderly
increases the disease burden
• 65% of Indian population lives in rural areas
while only 2% qualified medical doctors are
available
• Government spending on Health care continues
to be one of the lowest in the world
Page 45
46. INDIAN SCENERIO…
• Penetration of Med claim is currently done by
state-owned insurance companies, covering only
about 2.5 million people i.e. less than 0.50% of
the country’s population
Page 46
47. INDIAN SCENERIO…
• Report on National Commission on Macroeconomic and
Health, 2005
Households undertook nearly three- fourths of all
health spending
Public spending was only 22%
Public private health spending ratio :
In India-1:4
In China- 2:3
In Pakistan- 1:3
Page 47
49. Health Expenditure
Central Government :05.2%
State Government :15.2%
Municipal Corp. & Private Donors:
01.3%
Insurance & Third party: 03.3 %
Out of Pocket: 75%
Page 49
50. Public private share of care
Immunizations
Antenatal Care
Institutional Deliveries
Hospitalization
Outpatient Care
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100
%
Public-Private Sector Shares
Private
Public
Page 50
51. Private Health Service
Providers
• World Bank (2004) estimated that at independence the
private sector in India had 8% of health care facilities.
Today 93% of all hospitals, 64 %of beds, 80-85% of
doctors, 90% of out patients and 60% of inpatient are in
private sector.
• Private health sector has over 71,000 crore market in
India
• The CII McKinsey report of 2004 expects it to grow to
156,000 crore by 2012
Page 51
52. Reasons for lack of access to
Govt facilities
• Better availability
• Convenience
• Perceived quality of private care
Page 52
53. Health expenditure in India is dominated by private
spending and inadequate public spending has become
a common feature
%
Brazil
3.2
Korea
1.8
Thailand
1.2
China
0.7
India
0.9
Inter- country comparison of public expenditure on
Health as a % GDP
Page 53
54.
Per ’000 pop
2001*
India
Beds
Other low income
countries (e.g., subSaharan Africa)
World average
1.8
7.4
Nurses
Per ’000 pop
2001*
0.9
1.0
4.3
3.3
1.2
1.5
High income countries (e.g.,
US, Western Europe, Japan)
Per ’000 pop
2001*
1.5
Middle income countries
(China, Brazil Thailand, South
Africa, Korea)
Physicians
1.6
1.9
1.8
1.5
7.5
3.3
Page 54
56. GOI is adopting alternative means
of financing such as seeking loans from the
World Bank and other international financing
institutions to upgrade and manage the labour
welfare and health programs (such as National
Family Welfare Program and Employee State
Health Insurance Scheme) in the country
Page 56
57. ESTABLISHMENT OF CORPORATE
HOSPITALS
• GOI has encouraged the establishment of corporate
hospitals in order to improve the quality of healthcare.
• These corporate hospitals have tie-ups with most
insurance companies and large business organizations
to provide superior healthcare for the employees.
• Eg: Apollo Hospital chain, Escorts Hospital, Tata
Memorial Hospital, Max Healthcare, and Fortis Hospital
chain from Ranbaxy
Page 57
58. Employee health care reform in
India
• Economic reforms was launched in India in 1991
• In addition to the involvement of the public and
private sector corporations, various government,
international and multi-lateral health agencies,
and other private stakeholders such as private
health insurers got involved in the reform
process.
Page 58
59. Social Insurance Scheme
• Covers only 3% of population
• Employees State Insurance Scheme
(ESIS)
• Central Government Health Scheme
(CGHS)
Page 59
60. The Employee State Insurance
• ESI provides six social security
benefits to employees:
1. Medical benefit
2. sickness benefit
3. maternity benefit
4. disablement benefit
5.dependant’s benefit
6. funeral expenses
Page 60
61. ESIC
• Insurance system which provides both cash and
medical benefits
• Spread over 677 centers in 25 states & union
territories across India, covering 7.8 million
employees and more than 25 million
beneficiaries
Page 61
62. Public Private Partnership
• means to bring together a set of actors for the
common goal of improving the health of a
population based on the mutually agreed roles
and principles
-WHO 1999
Page 62
63. Public Private Partnership
• Entrusting Health Centers to NGO
Special features:
PHC and CHCs handed over to
NGOs
Finances managed by Govt.
Operations managed by NGO
Page 63
64. It is employed in
• disease surveillance
• purchase and distribution of drugs in bulk
• contracting specialists for high risk pregnancies
• national disease control programs
• adoption and management of primary health centers
• contracting out medical education and training
• engaging private sector consultants
• Telemedicine
• Contracting out of Information, Education &
Communication (IEC) services
Page 64
65. Community based Participatory
research
• Medical officers to use community based
participatory research to partner with
community and develop, test and
disseminate programs that they can
sustain and improve health.
Page 65
66. NRHM
• National Rural Health Mission was launched 12 th
April, 2005 with an objective to provide effective
health care to the rural population
• improving access
• enabling community ownership
• strengthening public health systems for efficient
service delivery
• Enhancing equity and accountability
• Promoting decentralization
Page 66
67. Janani Suraksha Yojana
and ASHA
NRHM
↓↓ all MMR
& IMR
JSY
Antenatal Check up
Institutional Care during delivery
Immediate post-partum
(coordinated care)
↑↑Institutional
Deliveries
in BPL families
Cash assistance
Page 67
71. Strengthening Public Health
Delivery in India
• New concept of Indian Public Health
Standards introduced
• Indian Public Health Standards (IPHS) are
set of standards envisaged to improve the
quality of health care delivery in the
country under the National Rural Health
Mission.
Page 71
72. Strengthening Sub-centres
• Each sub-centre will have an Untied Fund
for local action @ Rs. 10,000 per annum.
• Maintaining Logistics: Supply of essential
drugs, both allopathic and AYUSH, to the
Sub-centres.
• Postings of Additional ANMs wherever
needed
Page 72
75. Sanitation and Hygiene
• Total
Sanitation
Campaign
(TSC)
implemented through guidance of District
Health Mission
• Components of TSC include IEC activities,
rural sanitary marts, individual household
toilets, women sanitary complex, and
School Sanitation Programme
Page 75
76. Strengthening Disease Control
Mechanisms
• National Disease Control Programmes
have been redefined and updated
• New Initiatives launched for control of Non
Communicable Diseases.
• Disease surveillance system have been
decentralized with the launch of IDSP
Page 76
77. Human Resources
• Appointment of Contractual staff
• Interest free loan for two wheelers to
ANM
• Reorganization of the entire cadre of
PMO
Page 77
78. Reorganization & Restructuring
• Ur ba n Heal t h c a r e
Lack of health infrastructure in urban areas.
Project proposed for primary health care in
urban slums.
Towns with less than one lakh population to be
covered.
1 FHW per 25,000 population and 1 FHV per
1,000 population in urban slums.
Page 78
79. Improving MIS through
computer applications.
• GIS applications
Village-wise Data of prevalence of disease
Utilized for micro-planning of disease control
activities
• Web based reporting of RCH
At state level computer generated reports are
received
Page 79
80. School Health check-up Programme
• Check up
• Referrals
• Preventive measures
• Treatment
• Submission of report
• Remedial measures
Page 80
81. MEDICAL TOURISM
• India is a popular destination for medical tourist
who receive effective medical treatment at lower
costs than in developed countries
• As the Indian healthcare delivery system strives
to match international standards the Indian
healthcare industry will be able to tap into a
substantial portion of the medical tourism market
Page 81
82. MEDICAL TOURISM
• Reduced costs, access to the latest
medical technology, growing compliance
to international quality standards and ease
of communication all work towards India’s
advantage
Page 82
83. MEDICAL TOURISM
•
A recent CII-McKinsey study on healthcare says Medical
Tourism alone can contribute Rs. 5,000-10,000 crores
additional revenue for tertiary hospitals by 2012, and will
account for 3-5 per cent of the total healthcare delivery
market.
• What India needs to do is to strengthen basic
infrastructure like Airports, Power, Roads etc. to support
these initiatives.
Page 83
84. PROBLEMS
• lack of sufficient evidence based
information about, and the impactassessment of various initiatives
• Providing employee health insurance
cover is not a mandatory requirement in
the private sector in India till now
Page 84
85. PROBLEMS
• Local authorities have been given
authorities to implement national
programmes but there is no financial
authority
Page 85
86. FICCI Healthcare Excellence
Awards 2009
State Government with Excellence in
Reforms
• Government of Tamil Nadu
• Government of Gujarat
Page 86
87. As a NURSE
• Nursing personnel must understand the
magnitude of this health challenge and take
coordinated action to promote healthy lifestyles,
prevent disease and provide health care to those
in need.
• taking preventive, promotive and rehabilitative
primary healthcare services to the doorsteps of
our citizens
Page 87
