System Model for Health Care PDF

MEDTOU SYSTEM MODEL FOR HEALTH CARE AGEN DA In order to meaningfully explore the types of healthcare, systems used across the globe, it is important to first understand what a healthcare system actually is. Broadly speaking, a healthcare system is a societal tool developed t...

MEDTOU SYSTEM MODEL FOR HEALTH CARE AGEN DA In order to meaningfully explore the types of healthcare, systems used across the globe, it is important to first understand what a healthcare system actually is. Broadly speaking, a healthcare system is a societal tool developed to help not only treat sick individuals, but to also keep people healthy and to sometimes aid financially withtypes There are four medical care. of healthcare systems used in the Western world. These systems include the Beveridge model, the Bismarck model, the national health insurance model, and the out-of-pocket model. BEVERIDGE MODEL The Beveridge model is named for its creator, an influential and inventive British reformer named William Beveridge. In this system, healthcare is provided for all citizens by the government. Much like firefighters, law enforcement, and other public services, healthcare through the Beveridge model is funded using citizens' taxes. This is also sometimes referred to as a single-payer national health service, as it is paid for exclusively by the government and is provided on a national scale.  BEVERIDGE MODEL In the Beveridge model, citizens are never directly responsible for any of their medical bills. Physicians may be either government employees or private practitioners, but all are paid exclusively by the government. Generally, costs are low in these healthcare systems. This is because the government is the sole provider, therefore removing the profit incentive from healthcare. The cornerstone of the Beveridge model's foundation is the belief that healthcare is a right that all people should have access to. As such, healthcare is a guarantee for all citizens of a nation that utilizes this model. In the United States, veterans are provided with healthcare that is very similar to the Beveridge model.  BEVERIDGE MODEL Nations that utilize the Beveridge model include: ·The United Kingdom ·Spain ·Hong-Kong ·Cuba ·New Zealand ·Select places in Scandinavia The Bismarck model uses an insurance system and is usually financed jointly by employers and employees through payroll deduction. Unlike with the US insurance industry, Bismarck-type health insurance plans do not make a profit and must include all citizens.  NATIONAL HEALTH INSURANCE Under national health insurance programs, governments provide compulsory health insurance to all or parts of the population. Historically, such programs were first introduced to provide insurance to industrial workers at the end of the nineteenth century, with Bismarck's social insurance laws of 1883 as the first example (see Social Security; Welfare State, History of; Social Insurance: Legal Aspects). Over the course of the twentieth century, compulsory health insurance programs have been expanded to cover ever greater portions of national  NATIONAL HEALTH INSURANCE hence the term ‘national.’ National health insurance programs are in place in most of Europe, Latin America, Canada, Australia, and Japan. When the entire population is covered as a right of citizenship, these programs are said to be universal. Nevertheless, while the term ‘national health insurance’ connotes the compulsory provision of health insurance to broad sectors of the population, there is no generally accepted definition for the portion of the population to be covered or for the exact benefits to be provided  OUT-OF- POCKET The out-of-pocket model of health financing refers to a MODEL healthcare system where individuals pay for their medical expenses directly, without the involvement of any insurance or government funding. In this model, individuals are responsible for covering the costs of healthcare services out of their own pockets A FOUR-LEVEL MODEL OF THE HEALTH CARE In this model, adapted from Ferlie and Shortell (2001), the SYSTEM health care system is divided into four “nested” levels: (1) the individual patient; (2) the care team, which includes professional care providers (e.g., clinicians, pharmacists, and others), the patient, and family members; (3) the organization (e.g., hospital, clinic, nursing home, etc.) that supports the development and work of care teams by providing infrastructure and complementary resources; and (4) the political and economic environment (e.g., regulatory, financial, payment regimes, and markets), the conditions A FOUR-LEVEL MODEL OF THE HEALTH CARE SYSTEM A FOUR-LEVEL MODEL OF THE HEALTH CARE SYSTEM The Individual Patient We begin appropriately with the individual patient, whose needs and preferences should be the defining factors in a patient-centered health care system. Recent changes in health care policy reflect an emphasis on “consumer-driven” health care. The availability of information, the establishment of private health care spending accounts, and other measures reflect an increasing expectation that patients will drive changes in the system for improved quality, efficiency, and effectiveness. Overall, the role of the patient has The Individual Patient For example, continuous, real-time communication of a patient's physiological data to care providers could accelerate the pace of diagnosis and treatment, thereby reducing complications and injuries that might result from delays. Remote (e.g., in-the-home, on-the-go) monitoring, diagnosis, and treatment would make care much more convenient for patients, save them time, and conceivably improve compliance with care regimes (see paper by Budinger in this volume). Communication technologies also have the potential to change the nature of the relationship between patient and provider, making it easier for patients to develop and maintain trusting relationships with their The Individual Patient Asynchronous communication also has the potential to significantly improve quality of care. The easy accessibility of the Internet and the World Wide Web should enable all but continuous inquiries and feedback between patients and the rest of the health care system ( IOM, 2001). The World Wide Web has already changed patients' ability to interact with the system and to self-manage aspects of their care. One of the fastest growing uses of the these communication technologies is as a source of medical information from third parties, which has made the consumer (i.e., the patient) both more informed, and, unfortunately, sometimes misinformed. Some of the improvements just described are available today, some are under study, and some are as much as a decade away from realization. Thus, research is still an essential component in  CARE TEAM The care team, the second level of the health care system, consists of the individual physician and a group of care providers, including health professionals, patients' family members, and others, whose collective efforts result in the delivery of care to a patient or population of patients. The care team is the basic building block of a “clinical microsystem,” defined as “the smallest replicable unit within an organization [or across multiple organizations] that is replicable in the sense that it contains within itself the necessary human, financial, and technological resources to do its work” (Quinn, 1992).  CARE TEAM In addition to the care team, a clinical microsystem includes a defined patient population; an information environment that supports the work of professional and family caregivers and patients; and support staff, equipment, and facilities ( Nelson et al., 1998). Ideally, the role of the microsystem is to “standardize care where possible, based on best current evidence; to stratify patients based on medical need and provide the best evidence-based care within each stratum; and to customize care to meet individual needs for patients with complex health problems” (Ferlie and Shortell, 2001). Most health and medical services today, however, are not delivered by groups or teams  THE ORGANIZAT ION The organization encompasses the decision-making systems, information systems, operating systems, and processes (financial, administrative, human-resource, and clinical) to coordinate the activities of multiple care teams and supporting units and manage the allocation and flow of human, material, and financial resources and information in support of care teams. The organization is the business level, the level at which most investments are made in information systems and infrastructure, process- management systems, and systems tools.  THE ORGANIZAT ION Health care organizations face many challenges. In response to the escalating cost of health care, government and industry—the third-party payers for most people—have shifted a growing share of the cost burden back to care providers and patients in recent years. As a result, hospitals and ambulatory care facilities are under great pressure to accomplish more work with fewer people to keep revenues ahead of rising costs.  THE POLITICAL AND ECONOMIC ENVIRONMENT The fourth and final level of the health care system is the political, economic (or market) environment, which includes regulatory, financial, and payment regimes and entities that influence the structure and performance of health care organizations directly and, through them, all other levels of the system. Many actors influence the political and economic environment for health care.  THE POLITICAL AND ECONOMIC ENVIRONMENT The federal government influences care through the reimbursement practices of Medicare/ Medicaid, through regulation of private-payer and provider organizations, and through its support for the development and use of selected diagnostic and therapeutic interventions (e.g., drugs, devices, equipment, and procedures). State governments, which play a major role in the administration of Medicaid, also influence care systems. Private-sector purchasers of health care, particularly large corporations that contract directly with health care provider organizations and third-party payers (e.g., health plans and insurance companies), are also important environment-level actors, in some cases reimbursing providers for services not covered by the federal government.  A SYSTEMS VIEW OF HEALTH CARE the health care delivery system was described as a “cottage industry.” The main characteristic of a cottage industry is that it comprises many units operating independently, each focused on its own performance. Each unit has considerable freedom to set standards of performance and measure itself against metrics of its own choosing. In addition, cottage industries do not generally attempt to standardize or coordinate the processes or performance of Unit A with those of Units B, C, and so on. Indeed, this is an apt characterization of the current health care delivery system. Even in many hospitals, individual departments operate more or less autonomously, creating so-called “silos.” Many physicians practice independently or in small groups, and ambulatory clinics, pharmacies, laboratories, rehabilitation clinics, and other organizations—although part of the delivery system— often act as independent entities. We often call this arrangement a “health care system,” even though it was not created as a system and has never performed as a system.  A SYSTEMS VIEW OF HEALTH CARE Moving from the current conglomeration of independent entities toward a “system” will require that every participating unit recognize its dependence and influence on all other units. Each unit must not only achieve high performance but must also recognize the imperative of joining with other units to optimize the performance of the system as a whole. Moreover, each individual care provider must recognize his or her dependence and influence on other care team members (e.g., specialists in different fields, pharmacists, nurses, social workers, psychologists, physical therapists, etc.) ( IOM, 2003). These are the underlying attitudes that support a systems approach to solving problems.  Optimizati on It is easy to show mathematically that the optimization of individual units rarely, and only under highly improbable circumstances, results in optimization of the whole. Optimization is determined by a variety of metrics, including the productivity of a unit, the quality of service, the use of physical resources, or a combination of all of these. Optimization of the whole requires a clear understanding of the goal of the overall system, as well of interactions among the subsystems. The whole must be recognized as being greater than the sum of its parts.  THE ROLE OF INFORMATION AND COMMUNICATIONS TECHNOLOGY Many industries have attempted to use information/ communications systems in place of manual operations, such as record keeping. But information/communications systems can be used for much more than electronic record keeping. With incredible advances in computational speed and capacity and parallel advances in computer software, clinical information and communications systems can provide immediate access to information, including patient-based information (e.g., past laboratory values and current diagnoses and medications), institution-based information (e.g., drug-resistance patterns of various bacteria to different antibiotics), profession-based information  THE ROLE OF INFORMATION AND COMMUNICATIONS TECHNOLOGY (e.g., clinical-practice guidelines, including summaries of recommended best practices in various situations), real-time decision support (e.g., alerts about potential drug interactions or dosing patterns in a patient with a compromised drug-metabolism mechanism), practice-surveillance support (e.g., reminders about upcoming screening tests recommended for a patient), and population health data (e.g., for epidemiological research, disease and biohazard surveillance, notification of post-introduction adverse drug events).  INPUTS In a health system, ‘inputs’ are the information, mechanisms, and/or resources that go into it so that it can function. There are two types of inputs important for PHC -- “hardware” inputs (funds, human resources, medicines and supplies, physical infrastructure/facilities, and information systems) and “software” inputs (financing mechanisms, provider payment incentives, regulations, and market structure). At the point of care, inputs are transformed into outputs and outcomes via health service delivery processes Core components of Inputs Core components of Inputs  Abstract A citizen point of view on the healthcare system, its processes and their improvement is emphasised. From this point of view, five main processes are identified: Keeping Healthy, Detecting Health Problems, Diagnosing Diseases, Treating Diseases and Providing for a Good End of Life. The citizen should be looked upon as a cocreator of value and improvement of these processes.  Five main processe s The concept ‘work process’ has been used for a very long time1 to denote sets of repeatable value creating activities subject to improvement.2 Shewhart3 4 also emphasised the process as a means to produce value for the customer, but with a varying quality. By identifying and removing assignable causes of variation, the process could be made predictable with only chance causes of variation left in the process. Donabedian5 was an early proponent of the use of the process concept in healthcare. He identified the importance of looking at the organisational structure6 and the processes involved in producing outcomes for the patients. Batalden and Stoltz,7 basing their contributions very much on Deming,8 9 extended the concept to systems by describing a general framework for quality improvement in healthcare. Processes can be studied from a department, organisation10 or industry perspective. If we focus on the complete healthcare system, it would be natural also to look upon the processes from a citizen's point of view. From that perspective, the following five main processes are identified  Keeping healthy (prevention) This includes physical fitness, bed nets against malaria, a good diet, clean drinking-water and less use of tobacco; the list goes on. We could have the best hospital care, but it would not achieve much if this first process is not functioning well. The use of personal improvement projects is a mechanism to improve health at the individual level. However, the healthcare system also has to engage in proactive prevention of future illness. If a 4-year old with a weight problem is left to habits already well developed, subsequent problems not only with health, such as increased risk of diabetes and subsequent consequences, but also social problems may arise. Another illustration is smoking cessation: societal support is important, as illustrated by successful legal activities in this area.  Detecting health problems If people do not come forward, it can be difficult for the health system to help them. Proactive outreach on the part of the healthcare system is important. Cancer screening is an illustrative example. If a fast-growing malign melanoma is growing without detection, the effectiveness of the diagnostic and treatment processes might be of little help. The citizens could be more actively engaged in monitoring their own health status. Longitudinal data are more useful if collected regularly. Daily measurement of hypertension or blood sugar can provide more information than can be collected once every few months in a doctor's office.  Diagnosing diseases This is the process needed to trigger the next process of treatment. There are few things less cost- effective than the wrong diagnosis. Timeliness of diagnosis is critical for many disease paths. The healthcare system provides the knowledge and methods for this process.  Treating diseases Curing and caring is at the core of most of today's discourse on quality improvement in healthcare. Through self-management, the citizen can work as a stronger partner with the healthcare system to improve this process. Providing for a good end of life An effective, but endless treatment process is not always consistent with a good end of life. One shortcoming of an effective treatment process that is often not discussed is when the treatment obstructs the patients' quality of life in their last period of life. For many diseases, ageing is the root cause leading to the deterioration of all human systems—some slower, some faster. The medical specialties are divided by organ/symptom area: the heart, eyes, hearing, mental health, etc. What is considered good care from a symptom area specialist may not create a good end of life. A holistic point of view is required; therefore, there is a need for more physicians in the specialty of geriatric care.  Discussion Of course, these processes do not occur in neat succession; they may be in operation simultaneously, in parallel or iteratively. In happy situations, the first transforms into the last one.  Health outputs and output-based efficiency measures Health output indicators provide information on the quantity of goods and services provided by health care systems. When considered together with input indicators, they can provide some measures of productivity or efficiency in health care delivery. Key indicators of health care activities include doctor consultations, the occupancy rates of hospital beds and the average length of stay in hospitals.  Health outputs and output-based efficiency measures Positive patient feedback was defined as a response from healthcare service users, families or the community indicating concordance between desired and actual experiences regarding care or treatment, delivered to healthcare staff or systems.