This document discusses several enduring problems in healthcare systems including uncertainty about clinical effectiveness due to poor quality research, persistent variations in clinical practice, patient safety issues, reluctance to manage skill mix, and poor outcome measurement. It also outlines some achievements of the UK healthcare system such as the establishment of NICE to evaluate clinical and cost effectiveness, introduction of targets to reduce wait times, and beginning to benchmark safety incidents. However, it notes continuous reorganizations have not been properly evaluated and there is a need for greater focus on improving average performance and ensuring best practices are universally adopted.
Automated Post-Discharge Care: An Essential Tool to Reduce ReadmissionsPhytel
Readmissions are a major problem in U.S. healthcare. Nearly one in five Medicare patients that are discharged from the hospital returns there within 30 days, and between 50 percent and 75 percent of those readmissions are considered preventable. Medicare pays about $17 billion annually for 2.5 million rehospitalizations of its beneficiaries and other payers spend roughly the same amount every year for all readmissions of non-Medicare patients.
Is complementary and alternative medicine (CAM) cost-effective? a systematic ...home
Whereas the number and quality of economic evaluations of CAM have increased in
recent years and more CAM therapies have been shown to be of good value, the majority of CAM
therapies still remain to be evaluated
The Role of Collaborative Arrangements on Quality Perception in Ambulatory CareBruno Agnetti
Il pronto intervento italiano aveva posto un accento particolare sulla promozione di nuove modalità organizzative. Alcuni studi hanno analizzato il loro impatto sulla percezione della qualità. Con l'obiettivo di esaminare i clienti 'e medici' in cura ambulatoriale all'interno dei diversi modelli organizzativi, abbiamo studiato 96 pazienti (di età compresa tra i 18-80 anni) e 22 medici (M = 50,33 anni).
2 8 5L e a r n I n g o b j e c t I v e sC H A P T E R.docxlorainedeserre
2 8 5
L e a r n I n g o b j e c t I v e s
C H A P T E R 1 0
Q U A L I T Y M A N A G E M E N T I N
T H E P H Y S I C I A N P R A C T I C E
Quality and reliability are system properties.
—W. Edwards Deming
➤ Articulate the nature of performance management.
➤ Describe the approaches to performance improvement.
➤ Appreciate the impact of variation on performance.
➤ Discuss the components of the Triple Aim.
➤ Describe process improvement.
In t r o d u c t I o n
One of the most important issues to address in the medical practice is the quality and
safety of the care provided to patients. The Institute of Medicine (IOM 2001), a presti-
gious branch of the National Institutes of Health, stated in its landmark report Crossing the
Quality Chasm: A New Health System for the 21st Century, “In its current form, habits, and
environment, American health care is incapable of providing the public with the quality
health care it expects and deserves.”
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EBSCO Publishing : eBook Academic Collection (EBSCOhost) - printed on 4/16/2020 7:48 PM via SUNY CANTON
AN: 1839064 ; Wagner, Stephen L..; Fundamentals of Medical Practice Management
Account: s8846236.main.ehost
F u n d a m e n t a l s o f M e d i c a l P r a c t i c e M a n a g e m e n t2 8 6
Another historic IOM (2000) report, To Err Is Human: Building a Safer Health
System, indicated that a shocking number of people—an estimated 44,000 to 98,000 per
year—are harmed by the healthcare system. A more recent study found that this number
has increased since publication of the 2000 IOM report despite substantial efforts to
improve. Medical errors have now become the third leading cause of death in the United
States (Makary and Daniel 2016).
The complexity of medical service and the inconsistency with which these services
are delivered, not to mention the fragmented nature of the system, have led to a number
of quality concerns (Mosadeghrad 2014), including a lack of systematic approaches to care
delivery and quality improvement. Efforts to improve quality in the medical profession
have a long tradition of focusing on individual performance versus system performance.
Exhibit 10.1 illustrates the potential flaw in this thinking. The bell-shaped curve, P-1,
represents the overall performance of any given system. Curve P-2 illustrates an improved
system of performance where the median performance is moved from M-1 to M-2. If an
organization seeks to improve by only focusing on the low performers, it experiences only
a small improvement, shown as I-1. By improving th ...
BHA 3002, Health Care Management 1 Course Learning Ou.docxtarifarmarie
BHA 3002, Health Care Management 1
Course Learning Outcomes for Unit II
Upon completion of this unit, students should be able to:
6. Analyze the finance system in a healthcare organization.
6.1 Examine key differences between for-profit, not-for-profit, and public healthcare facilities.
6.2 Explain the process of creating and balancing a healthcare facility budget.
8. Evaluate ways to improve the quality and economy of patient care.
8.1 Describe the process of quality review and privileging for physicians.
8.2 Discuss the importance of quality initiatives, quality equipment and supplies, and quality
regulations.
8.3 Identify a management problem in a healthcare organization.
Course/Unit
Learning Outcomes
Learning Activity
6.1
Chapter 3 Reading
Unit Assessment
6.2
Chapter 3 Reading
Unit Assessment
8.1
Unit Lesson
Chapter 4 Reading
Unit Assessment
8.2
Unit Lesson
Chapter 4 Reading
Unit Assessment
8.3
Unit Lesson
Chapter 4 Reading
Unit II Project Topic
Reading Assignment
Chapter 3: Financing the Provision of Care
Chapter 4: Quality of Care
Unit Lesson
Evidence-Based Performance Measures
One of the hottest topics in healthcare administration today is evidence-based performance, and you certainly
need a solid understanding of this process in order to function effectively as a healthcare leader moving into
the future. American health care needs to improve. There is no doubt about that. Americans deserve more
bang for the buck that they spend on medical services. One of the most important initiatives to make that
happen is a move to more evidence-based practice.
What evidence-based performance is truly all about, first and foremost, is the patient (UT Health, 2015). In
particular, it is all about making sure that the patient receives care based upon the best and latest research
that is available for the patient’s own particular health problem or set of health problems. It is about giving the
right care, every time, for every patient. Other benefits of a solid evidence-based medicine program include
the ability to assure your own community that your hospital provides high quality care and that you are doing
your own quality review studies to make sure of this. Finally, evidence-based medicine makes sense because
UNIT II STUDY GUIDE
Financing and Quality for
Health Care
BHA 3002, Health Care Management 2
UNIT x STUDY GUIDE
Title
the Centers for Medicare Services (CMS) demands it of us. They will actually pay us more for our services if
we meet evidence-based performance criteria and goals, and they will financially penalize us if we do not
meet evidence-based goals. In short, there are many good reasons to implement evidence-based medicine in
your own medical facility.
Currently, there are several national focus areas for evidence-based medicine programs. These are heart
failure (HF), acute myocardial infarction (AMI), pneumonia (PN), and th.
Automated Post-Discharge Care: An Essential Tool to Reduce ReadmissionsPhytel
Readmissions are a major problem in U.S. healthcare. Nearly one in five Medicare patients that are discharged from the hospital returns there within 30 days, and between 50 percent and 75 percent of those readmissions are considered preventable. Medicare pays about $17 billion annually for 2.5 million rehospitalizations of its beneficiaries and other payers spend roughly the same amount every year for all readmissions of non-Medicare patients.
Is complementary and alternative medicine (CAM) cost-effective? a systematic ...home
Whereas the number and quality of economic evaluations of CAM have increased in
recent years and more CAM therapies have been shown to be of good value, the majority of CAM
therapies still remain to be evaluated
The Role of Collaborative Arrangements on Quality Perception in Ambulatory CareBruno Agnetti
Il pronto intervento italiano aveva posto un accento particolare sulla promozione di nuove modalità organizzative. Alcuni studi hanno analizzato il loro impatto sulla percezione della qualità. Con l'obiettivo di esaminare i clienti 'e medici' in cura ambulatoriale all'interno dei diversi modelli organizzativi, abbiamo studiato 96 pazienti (di età compresa tra i 18-80 anni) e 22 medici (M = 50,33 anni).
2 8 5L e a r n I n g o b j e c t I v e sC H A P T E R.docxlorainedeserre
2 8 5
L e a r n I n g o b j e c t I v e s
C H A P T E R 1 0
Q U A L I T Y M A N A G E M E N T I N
T H E P H Y S I C I A N P R A C T I C E
Quality and reliability are system properties.
—W. Edwards Deming
➤ Articulate the nature of performance management.
➤ Describe the approaches to performance improvement.
➤ Appreciate the impact of variation on performance.
➤ Discuss the components of the Triple Aim.
➤ Describe process improvement.
In t r o d u c t I o n
One of the most important issues to address in the medical practice is the quality and
safety of the care provided to patients. The Institute of Medicine (IOM 2001), a presti-
gious branch of the National Institutes of Health, stated in its landmark report Crossing the
Quality Chasm: A New Health System for the 21st Century, “In its current form, habits, and
environment, American health care is incapable of providing the public with the quality
health care it expects and deserves.”
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p
y
r
i
g
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t
2
0
1
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.
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EBSCO Publishing : eBook Academic Collection (EBSCOhost) - printed on 4/16/2020 7:48 PM via SUNY CANTON
AN: 1839064 ; Wagner, Stephen L..; Fundamentals of Medical Practice Management
Account: s8846236.main.ehost
F u n d a m e n t a l s o f M e d i c a l P r a c t i c e M a n a g e m e n t2 8 6
Another historic IOM (2000) report, To Err Is Human: Building a Safer Health
System, indicated that a shocking number of people—an estimated 44,000 to 98,000 per
year—are harmed by the healthcare system. A more recent study found that this number
has increased since publication of the 2000 IOM report despite substantial efforts to
improve. Medical errors have now become the third leading cause of death in the United
States (Makary and Daniel 2016).
The complexity of medical service and the inconsistency with which these services
are delivered, not to mention the fragmented nature of the system, have led to a number
of quality concerns (Mosadeghrad 2014), including a lack of systematic approaches to care
delivery and quality improvement. Efforts to improve quality in the medical profession
have a long tradition of focusing on individual performance versus system performance.
Exhibit 10.1 illustrates the potential flaw in this thinking. The bell-shaped curve, P-1,
represents the overall performance of any given system. Curve P-2 illustrates an improved
system of performance where the median performance is moved from M-1 to M-2. If an
organization seeks to improve by only focusing on the low performers, it experiences only
a small improvement, shown as I-1. By improving th ...
BHA 3002, Health Care Management 1 Course Learning Ou.docxtarifarmarie
BHA 3002, Health Care Management 1
Course Learning Outcomes for Unit II
Upon completion of this unit, students should be able to:
6. Analyze the finance system in a healthcare organization.
6.1 Examine key differences between for-profit, not-for-profit, and public healthcare facilities.
6.2 Explain the process of creating and balancing a healthcare facility budget.
8. Evaluate ways to improve the quality and economy of patient care.
8.1 Describe the process of quality review and privileging for physicians.
8.2 Discuss the importance of quality initiatives, quality equipment and supplies, and quality
regulations.
8.3 Identify a management problem in a healthcare organization.
Course/Unit
Learning Outcomes
Learning Activity
6.1
Chapter 3 Reading
Unit Assessment
6.2
Chapter 3 Reading
Unit Assessment
8.1
Unit Lesson
Chapter 4 Reading
Unit Assessment
8.2
Unit Lesson
Chapter 4 Reading
Unit Assessment
8.3
Unit Lesson
Chapter 4 Reading
Unit II Project Topic
Reading Assignment
Chapter 3: Financing the Provision of Care
Chapter 4: Quality of Care
Unit Lesson
Evidence-Based Performance Measures
One of the hottest topics in healthcare administration today is evidence-based performance, and you certainly
need a solid understanding of this process in order to function effectively as a healthcare leader moving into
the future. American health care needs to improve. There is no doubt about that. Americans deserve more
bang for the buck that they spend on medical services. One of the most important initiatives to make that
happen is a move to more evidence-based practice.
What evidence-based performance is truly all about, first and foremost, is the patient (UT Health, 2015). In
particular, it is all about making sure that the patient receives care based upon the best and latest research
that is available for the patient’s own particular health problem or set of health problems. It is about giving the
right care, every time, for every patient. Other benefits of a solid evidence-based medicine program include
the ability to assure your own community that your hospital provides high quality care and that you are doing
your own quality review studies to make sure of this. Finally, evidence-based medicine makes sense because
UNIT II STUDY GUIDE
Financing and Quality for
Health Care
BHA 3002, Health Care Management 2
UNIT x STUDY GUIDE
Title
the Centers for Medicare Services (CMS) demands it of us. They will actually pay us more for our services if
we meet evidence-based performance criteria and goals, and they will financially penalize us if we do not
meet evidence-based goals. In short, there are many good reasons to implement evidence-based medicine in
your own medical facility.
Currently, there are several national focus areas for evidence-based medicine programs. These are heart
failure (HF), acute myocardial infarction (AMI), pneumonia (PN), and th.
We don’t have a functional competitive market in health care in the U.S. Consequently, many of the attributes of competitive markets that are beneficial in our lives are not present in health care. One significant negative externality of a dysfunctional market is an inability to discern quality. Consumerism is critical. Includes data and analysis from the 5TH ANNUAL HEALTHGRADES PATIENT SAFETY IN AMERICAN HOSPITALS STUDY – APRIL 2008
The National Academies Health and Medicine DivisionAbout U.docxdennisa15
The National Academies
Health and Medicine Division
About UsPublicationsActivitiesMeetings
Announcement
Crossing the Quality Chasm: The IOM Health Care Quality Initiative
In 1996, after releasing America's Health in Transition: Protecting and Improving Quality, the IOM launched a concerted, ongoing effort focused on assessing and improving the nation's quality of care.
The first phase of this Quality Initiative documented the serious and pervasive nature of the nation's overall quality problem, concluding that "the burden of harm conveyed by the collective impact of all of our health care quality problems is staggering" (Chassen et al., 1998).
IOM Definition of Quality
The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.
This phase built on an intensive review of the literature conducted by RAND to understand the scope of this issue (Schuster) and a framework was established that defined the nature of the problem as one of overuse, misuse and underuse of health care services (Chassen et al). More specifically, the report Ensuring Quality Cancer Care (1999) documented the wide gulf that exists between ideal cancer care and the reality many Americans with cancer experience.
During the second phase, spanning 1999-2001, the Committee on Quality of Health Care in America, laid out a vision for how the health care system and related policy environment must be radically transformed in order to close the chasm between what we know to be good quality care and what actually exists in practice. The reports released during this phase—To Err is Human: Building a Safer Health System(1999) and Crossing the Quality Chasm: A New Health System for the 21st Century(2001)—stress that reform around the margins is inadequate to address system ills.
The series of IOM quality reports have included a number of metrics that illustrate how wide the quality chasm is and how important it is to close this gulf, between what we know is good quality care and what the norm is in practice.
To Err is Human put the spotlight on how tens of thousands of Americans die each year from medical errors and effectively put the issue of patient safety and quality on the radar screen of public and private policymakers. The Quality Chasm report described broader quality issues and defines six aims—care should be safe, effective, patient-centered, timely, efficient and equitable—and 10 rules for care delivery redesign.
Phase three of the IOM's Quality Initiative focuses on operationalizing the vision of a future health system described in the Quality Chasm report. In addition to the IOM, many others are working to create a more patient responsive 21st century health system, including clinicians/ health care organizations, employers/consumers, foundations/research, government agencies, and quality organizations. This collection of efforts focus reform a.
Patient Reported Outcomes (PRO) - Challenge and potential solutions.
Why and how can medical device and pharmaceutical companies, as well as the entire healthcare sector, leverage patient engagement with next-generation ePRO solutions?
Discover our white paper...
Professional Association MembershipExamine the importance ofdavieec5f
Professional Association Membership
Examine the importance of professional associations in nursing. Choose a professional nursing organization that relates to your specialty area, or a specialty area in which you are interested. In a 750-1,000 word paper, provide a detailed overview the organization and its advantages for members. Include the following:
Describe the organization and its significance to nurses in the specialty area. Include its purpose, mission, and vision. Describe the overall benefits, or "perks," of being a member.
Explain why it is important for a nurse in this specialty field to network. Discuss how this organization creates networking opportunities for nurses.
Discuss how the organization keeps its members informed of health care changes and changes to practice that affect the specialty area.
Discuss opportunities for continuing education and professional development.
Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.
This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.
References:
Explore the Advocacy page of the American Nurses Association (ANA) website.
URL:
https://www.nursingworld.org/practice-policy/advocacy/
Read Chapter 5 in
Dynamics in Nursing: Art and Science of Professional Practice.
URL:
https://www.gcumedia.com/digital-resources/grand-canyon-university/2018/dynamics-in-nursing_art-and-science-of-professional-practice_1e.php
this is the chapter 5
By June Helbig
“… nurses provide services that maintain respect for human dignity and embrace the uniqueness of each patient and the nature of his or her health problems, without restriction with regard to social or economic status.” (American Nurses Association, n.d.a, para 1)
Essential Questions
What significance does joining a professional organization have on nursing practice?
How can nurses contribute to legislative changes that impact nursing practice and patient outcomes?
Why is evidence-based practice (EBP) the gold standard in patient care protocol improvements?
Introduction
According to the American Nurses Association (ANA) there are currently 3.6 million registered nurses in the United States (American Nurses Association [ANA], n.d.b, para 12). The ANA is a professional nursing organization, which began when fewer than 20 nurses attended a convention in 1896. Nurses at the time were concerned with nursing practice standards and nurse competency. The ANA has since grown into an organization with interests in improving health care and setting standards for nursing practice. All nurses are represented regardless of status within the organization. The goal of professional organizations is to support nurses and improve the profession (ANA, n.d.c).
This chapter will explore the significance of joining professional organizati ...
Graham was invited to the weekly seminar series by the Royal Brompton Hospital to deliver a presentation on health economics pertinent to Respiratory medicine. They care for a large number of patients with complex lung diseases at the institution and juggle the varied issues of resource (human, structural or financial). As one of many examples, high cost drugs for treating relatively unusual conditions comes up for debate all too frequently. The audience included consultant physicians, senior and junior trainees, nurses and other allied health professionals.
Date: 7 March 2019
Location: The Royal Brompton, London, UK
CHD Secondary Prevention Clinics in Primary Care; a critical assessmentJosep Vidal-Alaball
There is a need for CHD secondary prevention in primary care. This need has been addressed providing specialized clinics run by nurses or GPs. Whether with this clinics we are meeting this need is a question to be answered.
Assignment 1Part 1 Defining the ProblemProblem Identification.docxtrippettjettie
Assignment 1
Part 1: Defining the Problem
Problem Identification
According to Ludwick and Doucette (2009), one of the primary issues in healthcare is the reduced standard of patient care due to the continued non-integration of technology in medical-based facilities. The result is a poor entry of patient data, coupled with a system that cannot be relied upon in the long term. In this context, Black et al. (2011) are of the opinion that it is mandatory for all healthcare facilities to incorporate electronic health records systems and shift from the use of manual-based recording strategies.
Comment by Author: Use all of participating authors the first time listing
Problem Statement
The continued utilization of manual health-based recording system in the contemporary society leads to reduced efficiency. It also negatively affects the overall outcome of healthcare delivery at the expense of the patient.
Problem Description
The continued use of paper-based records in the modern society is inefficient as compared to hospices that use electronic-based recording system. First, the use of the latter focuses on patient-centered care whereby there it leads to reduced repetition of tests, as there is no scattering of test results in various hospitals. In addition, the paper-based recording system is redundant as the access to a patient’s records by a medical health provider is limited by the location of the doctor as well as the time they can access the hospital (Black et al. 2011). However, the latter is not limited by the mentioned entities since data can be sent electronically at any time and place to the doctor. The problem is directly related to my discipline since patients that undergo recording of their personal information through the manual-based recording system are prone to medical errors. According to Ludwick and Doucette (2009), such errors may involve poor drug administration, especially if a patient may prove allergic to various subscribedprescribed medications. Besides, the electronic-based records will result in increased monitoring of a patient, which leads to faster healthcare delivery, which is the objective of studying my discipline.
Purpose Statement
The reduced efficiency coupled with the adverse outcome caused by paper-based recording systems will be obliterated upon the incorporation of the electronic-based recording system. The objective related to the implementation of the project is increased efficiency and improved quality of healthcare delivery to the patients.
Part 2: Defining a Searchable, Answerable Question:
Population/Patient Problem:
1. What are the efficiency rates concerning number of patients that are bound to benefit from the incorporation of the electronic-based records?
Comment by Author: Needs to clarify what the rates are referring? Efficiency of what?
2. Does the electronic health recording provide any unique advantages over the manual recording system regarding the health status, of a patient?
Interventio ...
27052024_First India Newspaper Jaipur.pdfFIRST INDIA
Find Latest India News and Breaking News these days from India on Politics, Business, Entertainment, Technology, Sports, Lifestyle and Coronavirus News in India and the world over that you can't miss. For real time update Visit our social media handle. Read First India NewsPaper in your morning replace. Visit First India.
CLICK:- https://firstindia.co.in/
#First_India_NewsPaper
Welcome to the new Mizzima Weekly !
Mizzima Media Group is pleased to announce the relaunch of Mizzima Weekly. Mizzima is dedicated to helping our readers and viewers keep up to date on the latest developments in Myanmar and related to Myanmar by offering analysis and insight into the subjects that matter. Our websites and our social media channels provide readers and viewers with up-to-the-minute and up-to-date news, which we don’t necessarily need to replicate in our Mizzima Weekly magazine. But where we see a gap is in providing more analysis, insight and in-depth coverage of Myanmar, that is of particular interest to a range of readers.
ys jagan mohan reddy political career, Biography.pdfVoterMood
Yeduguri Sandinti Jagan Mohan Reddy, often referred to as Y.S. Jagan Mohan Reddy, is an Indian politician who currently serves as the Chief Minister of the state of Andhra Pradesh. He was born on December 21, 1972, in Pulivendula, Andhra Pradesh, to Yeduguri Sandinti Rajasekhara Reddy (popularly known as YSR), a former Chief Minister of Andhra Pradesh, and Y.S. Vijayamma.
01062024_First India Newspaper Jaipur.pdfFIRST INDIA
Find Latest India News and Breaking News these days from India on Politics, Business, Entertainment, Technology, Sports, Lifestyle and Coronavirus News in India and the world over that you can't miss. For real time update Visit our social media handle. Read First India NewsPaper in your morning replace. Visit First India.
CLICK:- https://firstindia.co.in/
#First_India_NewsPaper
Future Of Fintech In India | Evolution Of Fintech In IndiaTheUnitedIndian
Navigating the Future of Fintech in India: Insights into how AI, blockchain, and digital payments are driving unprecedented growth in India's fintech industry, redefining financial services and accessibility.
In a May 9, 2024 paper, Juri Opitz from the University of Zurich, along with Shira Wein and Nathan Schneider form Georgetown University, discussed the importance of linguistic expertise in natural language processing (NLP) in an era dominated by large language models (LLMs).
The authors explained that while machine translation (MT) previously relied heavily on linguists, the landscape has shifted. “Linguistics is no longer front and center in the way we build NLP systems,” they said. With the emergence of LLMs, which can generate fluent text without the need for specialized modules to handle grammar or semantic coherence, the need for linguistic expertise in NLP is being questioned.
role of women and girls in various terror groupssadiakorobi2
Women have three distinct types of involvement: direct involvement in terrorist acts; enabling of others to commit such acts; and facilitating the disengagement of others from violent or extremist groups.
31052024_First India Newspaper Jaipur.pdfFIRST INDIA
Find Latest India News and Breaking News these days from India on Politics, Business, Entertainment, Technology, Sports, Lifestyle and Coronavirus News in India and the world over that you can't miss. For real time update Visit our social media handle. Read First India NewsPaper in your morning replace. Visit First India.
CLICK:- https://firstindia.co.in/
#First_India_NewsPaper
03062024_First India Newspaper Jaipur.pdfFIRST INDIA
Find Latest India News and Breaking News these days from India on Politics, Business, Entertainment, Technology, Sports, Lifestyle and Coronavirus News in India and the world over that you can't miss. For real time update Visit our social media handle. Read First India NewsPaper in your morning replace. Visit First India.
CLICK:- https://firstindia.co.in/
#First_India_NewsPaper
‘वोटर्स विल मस्ट प्रीवेल’ (मतदाताओं को जीतना होगा) अभियान द्वारा जारी हेल्पलाइन नंबर, 4 जून को सुबह 7 बजे से दोपहर 12 बजे तक मतगणना प्रक्रिया में कहीं भी किसी भी तरह के उल्लंघन की रिपोर्ट करने के लिए खुला रहेगा।
हम आग्रह करते हैं कि जो भी सत्ता में आए, वह संविधान का पालन करे, उसकी रक्षा करे और उसे बनाए रखे।" प्रस्ताव में कुल तीन प्रमुख हस्तक्षेप और उनके तंत्र भी प्रस्तुत किए गए। पहला हस्तक्षेप स्वतंत्र मीडिया को प्रोत्साहित करके, वास्तविकता पर आधारित काउंटर नैरेटिव का निर्माण करके और सत्तारूढ़ सरकार द्वारा नियोजित मनोवैज्ञानिक हेरफेर की रणनीति का मुकाबला करके लोगों द्वारा निर्धारित कथा को बनाए रखना और उस पर कार्यकरना था।
3. Introductory issues: health
production
The production of health: the primary
determinants of health are:
Genetic endowment: Larkin
Behaviour: parents again, income and
education
Health care: repair industry costing £105
billion
4. What is health?
“Health is a state of physical, mental and social well
being and not merely an absence of disease and
infirmity” WHO 1946
1845 Lunacy Act required doctors to report regularly
whether their patients were:
1. Dead
2. Recovered
3. Relieved
4. Unrelieved
Fines of £2 for failure to comply
Little attempt to measure and manage systematically
patient outcomes: no measure of success!
5. The distinction between
outputs and outcomes
An American health services researcher,
Donabedian, distinguished between:
1. Structure
2. Process
3. Outcome
Policy obsessed by “redisorganisation”, and an
assumption of a link between that and processes
and outcomes
What is “productivity”:a relation between inputs
and outputs, or a relationship between inputs and
outcomes?
6. Enduring problems
Five related issues in all health care systems,
public and private, create waste and
inefficiency:
1. Uncertainty about whether health
care/medicine “works”
2. Persistent variation in clinical practice, and the
failure to deliver to patients what “works”
3. Patient safety
4. Reluctance to manage skill mix
5. Outcome measurement
7.
8. „Flat of the Curve‟ Medicine?
Mark & Hlatky 2002, Fuchs 2004
9. What are the causes of uncertainty
about clinical effectiveness?
Not so much a problem of inadequate
funding of R&D and clinical trials, more that
the quality of research is poor.
1. The problems of designing and reporting
clinical trials e.g. the problem of
“surrogate” end points, poor outcome
measurement and biased reporting.
2. What is the comparator?
3. What patient groups are included in the
trial?
4. How long do you run the trial? Vioxx case
11. The failure to manage
variations in England
Priorities in Health and Personal Social Services
(1976) from the Department of Health advocated a
focus on day surgery and reducing length of stay.
The first article showing the day case surgery for
hernia repair was effective was in the Lancet in
1955 but there was little take up
Much still needs to be done to follow this advice 30
years later e.g. the English NHS Innovation and
Improvement Institute
Not just a NHS problem e.g. US Medicare and the
Dartmouth Atlas
12. Practice variations in the USA
US Medicare per capita spending in 2000 was
$10,550 per enrolee in Manhattan and $4823 in
Portland, Oregon. Differences are due to volume
effects rather than illness differences, socio-
economic status or price of services.
“Residents in high spending regions received 60%
more care but did not have lower mortality rates,
better functional status or higher satisfaction”
Fisher et al Annals in Internal Medicine(2003).
Potential savings of 30% of total Medicare
expenditure if high spenders reduce expenditure
and provide the safe practices of conservative
treatment regions? (Fisher in NEJM, October, 2003)
13. Practice variations: why do
they persist?
“the amount and cost of hospital treatment in a community
have more to do with the number of physicians there, their
medical specialties and the procedures they prefer than the
health of residents” Wennberg and Gittelsohn(1973 in the
journal Science)
The English Darzi report (2008) “rediscovered” clinical
variation as major policy issue!
Two policy issues:
1. Careful data analysis to identify outliers and to improve
average=mean performance
2. Use data analysis, benchmarking and improving average
performance by improving non-financial and financial
incentives
14. Patient safety: another
rediscovery!
UK cases :Shipman, the Bristol case and
two gynaecologists (Ledward and Neale)
Measuring error rates is difficult and the
evidence base is incomplete:
1. USA 3-5% of hospital admissions (Institute
of Medicine, 2000)
2. UK :two retrospective English studies of
case notes (Vincent et al, BMJ 2001, and
Sari et al (2006)) :10%
3. Australia: 16% (=10% if US criteria used)
15. Patient safety 2
US rates of 3-5% from tow local surveys
means that:
1. Medical errors in hospitals kill 44,000-98,000
Americans each year
2. Errors kill more Americans than motor vehicle
accidents (43,458), or breast cancer (42,297)
or AIDS (16,516)
3. Medication errors alone kill nearly three times
more Americans than 9/11
16. Patient safety 3
Types of errors
1. Medication: wrong drug, wrong dose
2. Surgery: wrong procedure
3. Infection control (Semmelweiss and Nightingale in
the 19th century) :what is the “cure” for poor
infection control?
What is the efficient level of errors (it may not be
zero!).
Where is the evidence base to inform efficient
investment in the “hygiene code”? E.g.
interventions to reduce central line infections,
C.Diff and MRSA, pressure sores etc?
18. Patient safety
The need to avoid “religious fervour” as seen in
the USA (www.ihi.org ) and at the World Health
Organisation
In particular:
1. Identify which of the many competing safety
interventions are efficient i.e. improve patient
outcomes at least cost
2. Recognise that the efficient level of public
safety is not zero errors!
19. Skill mix
Evidence from the Cochrane reviews that nurse
practitioners with full prescribing rights can act as
substitutes for GP (and patient like them better!)
Evidence that assistant practitioners can replace
registered nurses
Evidence that e.g.
1. Nurse anaesthetists can replace consultants
2. Nurse endoscopists are equally as proficient as
consultants
3. What else?
But are they used as complements or substitutes!
20. Measurement of success i.e.
outcome measurement
Mortality rates: use with caution!
1. Issues of small numbers
2. Issues around case mix adjustments
3. Use as screening device, not as a diagnostic
Quality of life , pre and post treatment: patient
reported outcome measurement (PROMs):
reintroduce the 1845 Lunacy Act
21. Labour government
achievements: evidence
based medicine and policy
The National Institute for Health and Clinical
Evidence (NICE). Many roles:
1. Evaluating the clinical and cost effectiveness of
new drugs (Technology Appraisal)
2. Producing clinical practice guidelines based on
clinical and cost effectiveness
3. Identifying what works in public health e.g.
minimum price for alcohol (and taxation of sugary
drinks?)
4. Improving the GP contract with evidence based
incentives (after investing nearly£1 billion in
incentives (quality outcomes framework(QOF)),
some of which are inefficient!)
22. And failures
Continuous “redisorganisation” of structures
with no attempt to evaluate them e.g. 2006
merger of PCTs (see Select Committee report on
Commissioning, 2010)
Introduction of interventions to help the
disadvantaged with little scientific evaluation of
effect e.g. “Head Start” (see the Select
Committee report on inequality, 2008)
23. Clinical practice variations
Targets work: e.g. 18 week waiting time for elective
procedures, cancer targets and 4 hour waits in A&E
But “advice” slow to take effect e.g.
1. NHS Institute for Innovation and Improvement
illustrates variation but how good is take up?
2. Poor management of the consultant contract: do
they do their sessions, how many do they treat in
their theatre sessions and what are their
outcomes: make national audits compulsory?
3. Need for greater transparency and accountability
24. Patient safety
C.Difficile and MRSA: avoidable infections with
better hand hygiene and better antibiotic policy
Beginning of benchmarking of rates of e.g. pressure
sores drug errors, wrong site surgery , falls and
items left in patients after surgery
E.g. failure to give patients prescribed drugs in
hospital. The new “quality account” of UH
Birmingham benchmarked drug omissions for the
first quarter of 2009 and is now managing them
down. Omission rates on their website: 11% for
antibiotics and 20% for other drugs.
To incentivise change should we “pay „em or flay
„em”? Are financial incentives the new “solution”!?
25. Potential risks of
incentivising change: pay for
performance (P4P)
It is difficult to see if employees make the right decision
e.g. the results of decisions may not be evident for years
P4P attracts risk takers rather than those who want steady
employment
Employees may manipulate the system
e.g. “exemptions” in the GP-QOF
P4P crowds out intrinsic rewards
i.e. P4P rewards may drive out the natural inclination of
workers to do a good job
Thus Akerlof and Kranton (2010) argue that “people want to
do a good job because they think they should and because it
is the right thing to do”
In efficient firms the goals of workers and their
organisations are aligned.
Comments on CQUIN - Maynard and Bloor, BMJ, February
2010
26. Skill mix
Invest in workforce substantial in terms of numbers
and pay increases
Innovatory practices but little evaluation
Problems remain:
1. Enforcement of contracts e.g. Agenda for Change
2. Lack of focus on what savings can be made by
altering skill mix
3. Continued wide pa y differentials e.g. porters and
other ancillaries near NMW and no quid pro quo
for consultant pay increases
27. Measuring Patient Outcomes in the English
NHS
Procedure Condition-specific Generic
Primary Unilateral Hip Replacement Oxford Hip Score EQ5D
Primary Unilateral Knee Replacement Oxford Hip Score EQ5D
Groin Hernia Repair None EQ5D
Varicose Vein Procedures Aberdeen Varicose Vein EQ5D
Questionnaire
Plus a standard set of patient-specific questions in all cases
Source: DH Operating Framework, Guidance on the routine collection of patient-reported outcome measures, Department of Health 2007
28. Changes in health for five surgical procedures
from LSHTM pilot
Hip Knee Hernia Veins Cataract
Improve 358 (82.1% ) 329 (73.3% ) 203 (47.2% ) 148 (55.6% ) 150 (20.9% )
No change 21 (4.8% ) 45 (10.0% ) 127 (29.5% ) 72 (27.1% ) 335 (46.7% )
W orsen 18 (4.1% ) 34 (7.6% ) 71 (16.5% ) 34 (12.8% ) 190 (26.5% )
Mixed change 39 (8.9% ) 41 (9.1% ) 29 (6.7% ) 12 (4.5% ) 42 (5.9% )
Total 436 449 430 266 717
Source:
Using the EQ-5D as a performance measurement tool in the NHS Nancy Devlin a,
David Parkin a, and John Browne b. EuroQol Group Scientific Plenary, Baveno, Italy, 11-
13th September 2008.
29. Overview for Labour
achievements in health care
Need to boast about and retain:
1. NICE: international excellence in analytical rigour
2. Targets
3. Focus on outcome measurement and management
Can do better on
1. Evaluation of “redisorganisations”
2. Evaluation of “storm” of policy initiatives
3. Low pay
4. “Value for money”: variations in processes and
outcomes ignored too often.
5. Commissioning: weak exercise of purchasing power.
6. Nursing processes and quality
30. The future……..
Budget squeeze with shift out of hospital financing
to primary and social care
|massive Tory “redisorganisation” from April 2012
PCTs gutted and replaced by GP consortia
NHS Board with Regional Offices replacing SHAs
Fate of targets and NICE uncertain, with the latter
threatened by industry
Static pay: but maybe pay cuts above say £25000
and graduated?
The challenge: measurement and management of
data and evidence rather than random “surgery”!