Health Care Management PDF

Health care management Objectives: By the end of this chapter, students should be able to: Identify management functions; Describe the planning function and its components; Use data/ information for situation analysis and identification and prioritization of health and health-rel...

Health care management Objectives: By the end of this chapter, students should be able to: Identify management functions; Describe the planning function and its components; Use data/ information for situation analysis and identification and prioritization of health and health-related problems; List the basic implementation functions; Define the principles of leadership and team building; Differentiate between managers and leaders; Define the evaluation function and demonstrate the ability to evaluate inputs, process, and outputs by the use of appropriate indicators; Define quality and identify the dimensions of quality in health care; Identify patient safety goals; Define the three major species of health economics: financing, cost analysis, and cost-effectiveness; Identify the principles of cost analysis and define some measures for cost containment. The subtopics include: I. Basic Management Skills II. Quality Management III. Patient Safety IV. Health Economics I.BASIC MANAGEMENT SKILLS: Management is both a Science and Art  As a SCIENCE, management has basic rules and principles. As an ART, successful managers learn through experience, they follow flexible, adaptive, innovative approaches to fulfill objectives. Management is an Art based on Science We all need management skills In all aspect so four life DEFINITIONS -Management is getting things effectively done to achieve desired objectives through proper planning, efficient implementation, and evaluation to assess achievements and identify the needs for re-planning. Management is thus a dynamic process. -Effectiveness is the degree to which a stated objective is being achieved. -Efficiency is the optimized (balanced) use of resources (human resources, equipment's, supplies, money, space, information and time. Good management is smooth functioning - Management is crucial for proper functioning of organizations, Programs or projects as well as for any daily activities that we are doing all the time. PRINCIPLES OF MANAGEMENT': l. Management by objectives:. Management is getting things done. The principle underlying this definition is commitment to achievements. 2.Learning from experience:.If the objectives have not been completely fulfilled, management analyses why? What are the constraints? And try to address them. 3. Division of labor:.Management is getting things done through people. Almost any activity needs more than one person to be accomplished; it needs TEAM WORK. 4. Convergence of work:. In team work the activities should be planned, assigned to team members (division of labor), directed, and coordinated to achieve the objectives. 5. Substitution& proper use of resources:. Management is efficient use of resources.. Resources are; manpower (human resources); material i.e., equipment's and supplies (physical resources); and money (fiscal resources), information and time.. Substitution of resources is meant to optimize the use of available resources to maximize the benefits gained.. The concepts of economy should be applied. 6.Delegation:. Delegation means that someone with authority gives another person the authority to take responsibility for a specific activity when the need arises.. The delegate cannot re-delegate the authority. 7.Setting priorities: This means two things: Be selective. Do not become over loaded with routine and unnecessary information. Make big decisions first (prioritization of decisions). THEMANAGEMENT FUNCTIONS: The management functions include: Planning functions Implementation functions 1. organization 4. coordinating 2. staffing 5. monitoring& control 3. directing. 6. supervision Evaluation functions PLANNING Planning is thinking before doing If you fail to plan you are planning to fail Definitions:. Planning is the process of formulating objectives and determining the steps which will be employed in attaining them.. Aplan states goals, objectives and out puts, and describe action and resources necessary to achieve them. The planning function includes: 1.Situation analysis. 2.Proble identification and priority setting. 3.Objective setting. 4.Selection of alternative solutions/ interventions. 5.Planning for resources. 6.Planning for monitoring and evaluation. 7.Planning for sustainability Types of planning: A. Strategic planning for long period from 5-15 years and for large organizations; e.g. Ministry of health, Faculty of Medicine ,etc.  B. Action Plan describes all the activities that have to be carried within a year. This plan also includes the budget needed. This can be further detailed in a three months implementation plan and further to a "doitlist" for one week or even one day.. Action plans are done for departments and smaller units; e.g., a PHC center, Department of Public Health. etc.. A doitlist can be done for a small unit or even for an individual.. Planning could be: 1. population-based/community-based planning. This would include intersectoral planning as appropriate. 2. Organization-based (Institution-based) planning-Every individual is involved in management and in developing plans for the organizations/ he is working for and for her/ himself as an individual. The planning process starts by identifying where we are now (the present situation), and where we want to be (the objectives/the desired situation), and then going through these even planning functions mentioned earlier. 1. SITUATION ANALYSIS The situation analysis depends on the level of planning. The situation analysis for population/community-based planning includes Demographic and socio-economic situation analysis includes the population size, age and sex composition of the population, average family size, per capita income, major economic activities, educational levels and il literacy rates, etc.  Epidemiologic situation analysis includes identification of the main health problems and their causes and underlying factors, vital rates for morbidity and mortality defined as age, sex, and cause specific. Health and other resources analysis would cover the health system in the country and other related sectors including educational resources; mass media activities; women and you the programs/projects; non-governmental organizations (NGOS) and cooperatives roles; social services in general; agriculture development activities; etc... See Community Needs Assessment written with PHC subject. 2. PROBLEM IDENTIFICATION AND PRIORITY SETTING Community health problems would be identified from the situation analysis and from expert's opinion. The problem may be an acute disease, a chronic disease, affecting all population groups, or a specific group of the population. Example of problems: High infant mortality rate, diarrhea among under five children, and malnutrition among under five, TB, obesity, coronary heart disease, adolescent's health problems, smoking, etc. Problem Definition Each problem should be clearly described. This should cover: (i) The nature, extent and magnitude of the problem, including who is affected, which age group, social class, and geographic area; (ii) The trend of the problem, whether increasing, decreasing or stationary.  (iii) Causes of the problem including the health related factors affecting the problem; (iv) Consequences of the problem. Diarrhea is of a high incidence rate among children in the first two years of life. It is especially high among lower social classes and in rural areas. The incidence is almost stationary over the past years. It increases with lack of environmental sanitation, and lack of healthy practices. It causes high death rate, and is also related to malnutrition. Analysis of the problem Community health problems can be analyzed by the problem tree indicating the problem, causes and contributing factors. This is done by asking your self 5 times why? Priority Setting With the limited resources we need to address the priority problem are as first. Priority setting would take into consideration the following: 1- The magnitude /extent of the problem (incidence and prevalence). 2- Seriousness of the problem which has four main components: ¥ Urgency: Some problems require a rapid response in order to prevent the spread of the problem or death; e.g. contaminated food, or radioactive waste. ¥ Severity: This is measured by immediate effects e.g. high mortality rates, or late sequelae in the form of complications or handicapping conditions. ¥ Economic costs: should include the costs of medical expenses, public services and Prevention programmes to the community. ¥ Impact on others: communicable disease control remains an important priority; however, other problems include water and air pollution, passive smoking, etc. 3- Effect on economy and productivity, and other socio- economic implications. 4- Availability of cheap feasible technologies for prevention and control At the end of this step it should be clear what are the priority problems to be dealt with first, among who, and where. 3. OBJECTIVE SETTING Goals and objectives clarify what need to be done If you do not have clear objectives one may end nowhere: The first step is to define the general objective of the programme/ project this spelled out in the goal activity. Goal: The goal is the intended end-result or achievement of programme project or activity. Specific objectives: One of the basic components of planning is to establish realistic objectives and targets. Objectives must be SMARI which stands for: Specific: Objectives should spell-out precise and clear statement of what is to be attained. Measurable: The objective should be measurable in order to be useful in assessing the degree to which has been achieved and to allow for monitoring and evaluation. Agreed Upon/Attainable (achievable, realistic). Objectives need 1o be agreed upon by the team responsible for implementing the activities to achieve them. Objectives should not be too difficult to achieve, or too modest. Relevant/appropriate: Objectives should help to solve the problems they are meant to solve. They should be pertinent to the situation and focus on the intended outcomes. Time-bound/time specific: Objectives must give clear dates/periods within which the stated objective has to be achieved. As you develop your objectives, be sure to keep in mind WHAT to be accomplished? HOW will it be done? WHEN will it be done? HOW MUCH will it cost? Objectives should consider the priority problems and the health-related problems: They  4. SELECTION OF ALTERNATIVE SOLUTIONS Criteria for selecting appropriate solutions: - The foreseen effectiveness of the proposed solution & visibly - Technical feasibility reflecting the use appropriate technology and availability of needed (human resources equipment and supplies and money) plus social acceptability. - Political and institutional support. Management Skills  Leading. 2. Solving problems  Planning. 4. Managing resources  Coordination. 6. Monitoring and evaluating  Communication. 8. Initiating and implementing change  Making decisions. 10. Team Work *ORGANIZATION-BASED PLANNING When people come together to combines their talents and efforts, they form organizations Examples of organizations - Civilization University is an organization. - Faculty of Medicine is an organization; each Department is an organization in itself. - The Ministry of Health and Population (MOH) is an organization; each Sector/Department is an organization in itself. - A PHC center/a Family Health Unit (FHU), each is an organization. - The World Health Organization (WHO) is an organization. Strategic planning in an organization An ongoing) program or a working organization would need to be reviewed and actions taken to improve performance, solve problems, and ensure, stability and sustainability Strategic planning is a methodology that could be followed to achieve such objectives. Strategic Planning is a3-5 years plans that would go into several steps to reach preset goals that the organization would like to achieve in the future. The steps to be followed in strategic planning include the following: 1. Organization vision and mission 2. Organization situation analysis Strengths, Weaknesses Opportunities, and Threats/Challenges (SWOT/SWOC). 3. Problem solving a. Identify the problems (the difference between the present and the desired situation) b. Prioritize the problems c. Establish goals and objectives d. Select solutions e. Continue with the following steps 4. Put an action plan (consider organization stability) S. Implement, monitor and evaluate 6.Update your plans Organization vision and mission Vision describes what the organization hopes to be in the future. It spells out the highest ideas and wishes and is a drive for Continuous improvement You must have a vision even for your self "If you can dream it, you can make it happen" Missions a Statement of the purpose. and main services of the organization, and how these services are offered Mission is flexible dynamic, and capable of responding to services as they occur. Example of a EHU mission: "The FHU represents the MOR in the catchments area served The Unit provides comprehensive health cares for individuals families and communities. This care covers physical social and psychological aspects throughout the human life cycle. All vertical programmers are delivered in an integrated pattern that fulfills the principles of quality, efficiency and effectiveness. The FHU implements Best Practices, and the staff provides evidence-based medical care. THE IMPLEMENTATION FUNCTION The implementation function includes: Organizing Staffing Directing and leadership Coordination of work and team building Recording and reporting Monitoring, and Supervision Leadership: Definition: "Leadership is the art or process of influencing people that they will strive willingly toward the achievement of a group goal." Characteristics of an effective leader: There are Personal characteristics and Behavioral characteristics Personal Characteristics: - Mental ability, intelligence, superior judgment, decisiveness. knowledge and fluency of speech. - Personality factors such as motivation. perception and attitude, self- confidence, personal integrity, the need to dominate, high concern about achievements, high task orientation and a desire for responsibility. Leaders are often active participants in various activities and events. they interact well with people. - Physical characteristics, as age, sex, appearance, general features. however, these. Are not usually important - Social background may be important for community leaders, but less so for organizational leaders. Behavioral Characteristics: Successful leaders use a particular style to influence their Subordinates, to accomplish the desired goals A leader behavior is affected by the assumptions she makes about the subordinates. There are two distinct types of leaders behavior; - Employee (Socio-emotionally-oriented leadership(initating consideration).  - Production (task)-oriented leadership (initiating structure). Team work - When ever an activity needs more than one person to be accomplished we need team work. - Teams can be from the same disciplines or different disciplines - All health activities need team work. - The health team in PHC includes staff from different disciplines: physicians, dentists, pharmacists nurses, technicians. sanitarians. health clerks, etc. TEAM: Together Each of us Achieves More In leading a health team one should take into consideration two basic principles: - Setting and sharing objectives -Motivating team members Monitoring Definition: Monitoring is the maintenance of regular checking of ongoing activities or programmes with respect to defined objectives. The purpose is to record what the system is actually doing at present and to detect possible deviations from the decided course of action. Where there are deficiencies, control and correction decisions and measures must follow. Monitoring concerned with - Work progress - Staff performance - Service achievement Supervision Definition: Supervision is to make sure that the staff performs their duties effectively It means that a supervisor helps and guides the staff and trains them as necessary in such a way that they become more competent and keep the standard of work EVALUATION Evaluation is a judgment of value based on measuring or assessing the achievements of program activities. It is essentially an information gathering process to determine the extent to which a programme/ project has been effectiveness and efficient. Evaluation is intended to measure the degree to which the objectives of the programme have been achieved; to identify pinfalls, and constraints; and to help re-planning for correction. Evaluation would thus consider all the steps of program planning, and implementation and will assess input process output outcome and impact Conducting Evaluation: - Describe the programme/project or activities to be evaluated - Determine the overall goals and specific objectives of the programme/project - Identify the indicators to be used. - Develop the evaluation design. - Collect data. - Analyze and interpret these data. - Utilize the evaluation results in decision making for corrective actions. In selecting the evaluation measures one should consider that these measures be oriented towards actions not opinions; use established measures rather than newly created ones; multiple rather than single: and whenever possible utilize available records and documents. Evaluation uses Indicators Indicators Measuring Effectiveness include: impact and outcome indicators. The sources of data are vital statistics and programmatic community – based surveys. Indicators Measuring Efficiency includes: input, process, and output indicators. The sources of data are service statistics at the health organization level e.g. MOH and its facilities. Input indicators: - Measure the resources of the organization (e.g. MOH) - Measure whether the used resources are satisfactory or not satisfactory Examples: number of health units/100, 000 population and number of MOH physicians/10,000 population. Sources of data are MOT documents. Process indicator - Measure the ability of the health organization in management of the resources. - Measure the efficiency at which the resources are managed, how the work is performed. - Examples: percent of physicians, Trained in maternal care, percent of MOH-PHC facilities that fulfill the quality standards according to the checklist. - Sources of data: MOH Statistics and report derived from supervision visits. Output indicators: - Measure the efficiency of the health facilities in management of the resources (e.g. providing quality services) to increase the utilization Caseload at the health facility. Examples: average number of ANC visits per mother. Outcome Indicators: - Measure the effectiveness of the program in achieving its strategic / programmatic objectives. - Measure the population knowledge. attitude and practice/behaviors related to the health program - Measure direct effect of the health services on the community. - Influenced by of the ability of the health system in covering the population with health services.  Examples: percent of children 24 months old who are fully immunized. Sources of data community based surveys. Impact Indicators: - Measure the effectiveness of the health program in achieving its goal - Reflect the health status of the community (morbidity and mortality) and fertility. - Measure the indirect effects of health services in achieving the goal Reflect the roller of both the health sector and others health-related sectors in achieving the health goals which need multisectoral approach. - Influenced by socioeconomic and cultural characteristics of the community. Examples: Maternal mortality ratio Infant morality rate and total fertility rate. ii. QUALIY MANAGEMENT Quality is the degree of adherence to pre-established criteria or standards The British Standards Institute (BSI) definition is, The totally of features and characteristics of the product or SERVICE that bears on its ability to satisfy stated or implied needs. However, the most informative definition is: Doing the Right thing, Right, the First time and Every time Dimensions of Quality in Health Care Dimensions of quality are the key themes within which quality should be assessed and measured. They represent the essential pillars for improvement, and the core need for health care to be. They include the following dimensions: 1. Accessibility The degree to which appropriate care and services are available timely geographically and financially and are able to meet the patient's needs. 2. Accessibility/ patient-centered  Delivering health cares which takes into account the preferences. needs and values of patients and the cultures of their communities. 3. Competency The practitioner's ability to produce both the health and satisfaction of customers. 4. Continuity The coordination of needed healthcare services for a patient or, the delivery of needed health care as a coherent unbroken succession of services. 5. Effectiveness The degree to which the care and services, are provided in the correct manner, that is adherent to an evidence base 5 to achieve the desired or projected outcome for the patient 6. Efficiency The cost -effective resourcing of systems or the relationship between the outcomes and the resources used to deliver patient care and services. 7. Equity Equity refers to fineness in dealing with the clients. 8. Prevention/Early Detection The degree to which interventions, including the identification of risk factors, promote health and prevent disease. 9. Safety Safety means the provision of services that do not harm the patient or the providers, or expose them to any unnecessary risk. (See iii. Patient Safety). 10. Timeliness The degree to which needed care and services are provided to the patient at the time they are needed, within the appropriate setting and without excessive waiting time. Customer Satisfaction Customer satisfaction is a major component of a quality management system. Authors defined quality practice as meeting the requirements of the customers. A customer is any person or organization that affects or is affected by the service/process. Customers are either: - External customers: e.g. patients contracting companies, suppliers - Internal customers: those are people working inside the healthcare facility e.g doctors, nurses, administrators. Accreditation Accreditation is a formal process by which an authorized body, either governmental or nongovernmental assesses and determines whether a healthcare organization meets applicable, predetermined and published standards. Quality Assurance (QA): Steps for Quality assurance contains all planned and systematic actions required to provide adequate confidence that a product or service will satisfy given requirements for quality. Steps for quality assurance cycle: 1. Develop a plan taking into consideration the elements for QA 2. Set standards which include: - practice guidelines - administrative procedure rules and regulations - specifications - performance standards: 3. Communicate standards for the people concerned to conform to. 4. Monitoring of implementation: Auditing 5. Identify problems, and put priorities 6. Define the problems; 7. Choosing a team to solve the problem; 8. Analyze and study the problem to identify the root causes (data collection, analysis and presentation, Fish-bone diagram); 9. Develop solutions and actions for quality improvement; 10. Implement and evaluate the quality improvement efforts Auditing Auditing means official examination Originally it was related to accounts Recently it has been used in relation to quality management It is an important step in the quality assurance, cycle. In CQI we talk about error or defect prevention. Primary prevention is reflected by doing the things right the first time. This, is achieved by conforming to STANDARDS. Secondary prevention is by avoiding repetition of defects to do the things right every time. This is achieved by AUDITING. Auditing is done periodically OR when something goes wrong (malpractice, adverse event, sentinel event). Auditing can be considered as a problem solving process This process must involve everyone who might have contributed to the problem Ask everyone to sit down and analyze: - What went wrong? - Why? - What actions need to be taken in Order not to repeat the problem? Auditing needs measurement It is based on a scientific approach to reach a decision based on information. Auditing involves the whole system.We have to examine the Structure inputs, Process, and outcome. There must be written Criteria /documented procedures/ standards to compare to. Auditing can be internal auding by the working team, usually the quality team if there is one in the organization; Or it may be external by external auditors. External auditing can be part of a process of accreditation. Auditing is Periodic whether there is defect or not II PATIENT SAFETY (Protect Patients from Harm) Definitions: “Patient safely is the avoidance., prevention and amelioration of adverse outcomes Or injuries stemming from the process of health care" “Patient safety: the reduction of risk of unnecessary harm associated with health care to an acceptable minimum" The overarching vision for patient safely is: “safety and quality for every person everywhere and every time" Aim of patient safety is to have a safe health system that minimizes harm to patients and consumers and reduces costs associated with preventable adverse events. The health system should be better informed, supported and organized to deliver safe and high-quality care. "Make a habit of two things: to help or at least to DO NO HARM" Appocrates In 1990s many countries. reported increasing numbers of patients harmed and killed due to health care errors estimated by 1 in every 10 patients around the world. In 1999 the media focused on the staggering reported statistics: 44,000 to 93,000 preventable deaths annually due to medical error, 7,000 preventable deaths related to medication errors alone. In 2004 the WHO called patient safely as an endemic concern; it identified six action areas and developed solutions to improve patient safety by achieving six important goals for patient safety. International Patient safety Goals: The following set of goals is mainly directed to hospital settings; Goal one: Identify patient correctly - Use at least two patient identifiers before administrating medications or blood products taking blood samples and other specimens for clinical testing, or providing any other treatments or procedures - Do not use patient room or bed number to identify the patient. Goal two: Improve effective communication among health care team: - For verbal or telephone orders verify the complete order by having the person receiving the order “read back" the complete order. - List the abbreviations and symbol that could cause confusion in order not to be used throughout the organization. Goal Three Improve the safety of using medication: - Enlist the Look-alike/sound-alike drugs used in the hospital and prevent error involving the interchange of these drugs. - Label medications medication containers (e.g. syringe, medicine Cups), or other solutions in peri-operative and other procedural settlings Goal Four: Eliminate wrong site wrong-Patient and wrong Procedure surgery. - Preoperative verification of the process via the available documents. - Surgical site marking process with patient involvement before anesthesia. Goal Five: Reduce the risk of health care acquired infections - Comply with hand Hygiene quid lines. - Implement practices to prevent central line associated blood stream infections and surgical site infections. Goal Six: Reduce the risk of patient harm resulting from falls: - Implement and evaluate a fall reduction program. The above mentioned are mainly for hospital settings: there are some specific issues for patient safety in maternity, in surgery anesthesia etc. Providers' safely is as important as patient safety Patient Safety in Primary Health Care The risks and solutions could be classified into 8 categories (medication infection diagnosis management, patient accidents, communication care medical devices/equipment) PHC providers should be aware of risks to patient safety The main patient risks in PHC are related to medication and infection control. Medication errors could be related to unclear prescription orders unnecessary drugs, too many drugs, not considering drug interactions, over prescription of antibiotics not considering drug interaction, no clear instructions to patients leading to wrong drug administration and non- Today, the World Health Organization ranks misuse and inappropriate use of antibiotics as one of the greatest threats to human health compliance, failure to tell the patient about side effects and proper action etc. IV. HEALTH ECONOMICS Definition Economics is the study of how people and society choose to employ resources, usually scarce/limited resources. Economics analyze the cost and benefits. Health economics is the application of economic principles to the health field. It is an important component of health management. Criteria for Evaluation of Financing Systems: 1. Equity 2. Efficiency 3. Sustainability & 4. Quality 1. Equity: Fair and Just Equity in health can be defined as the absence of systematic disparities in health (or in the major social determinants of health) between social groups who have different levels of underlying social advantage/ disadvantage that is, different positions in a social hierarchy. Types of Equity 2. Efficiency: measure of how well resources are used to produce the desired results It relates inputs to outputs of the health service. 3. Sustainability: A health service is sustainable when operated by an organizational system with long term ability to mobilize and allocate sufficient resources despite changes in the outside environment. 4. Quality: Quality of care is the extent to which actual caret is conforming to  preset criteria or standards for good care. COST-EFFECTIVENESS Effectiveness is a measure of the extent to which objectives are achieved. Cost-effectiveness analysis (CEA) is an analytical tool to help decision makers assess and compare the costs and Effectiveness of alternative ways of achieving an objective. It is a technique to identify the most effective use of limited resources Cost-effectiveness analysis is used for - Planning i.e prospective CEA to choose the most cost- effective intervention. However, in actual operation of a program the costs and effects may vary from those estimated in the planning process. - Evaluation of the interventions. Thus it is also used in a retrospective way to evaluate existing program. - The results of CEA are used for re-planning Some of the indicators used to measure the effectiveness of health improvement: - Morbidity reduction, decreased incidence Or prevalence of disease - The number of days disability prevent: The number of days on which individuals would have experienced some degree of dysfunction due to the relevant disease and can be weighted to reflect the degree of impairment - Mortality reduction which can be quantified as the number of averted deaths; can be adjusted to measure the potential years of life gained. Disability Adjusted life years (DAYs) DALYs for a disease are the sum of the years of life lost (YLL) due to premature mortality in a population and the years lost due to disability (YLD) for incident cases of the health condition The DALY is a health gap measure that extends the concept of potential years of healthy lie lost in sates of less than full health, broadly termed disability. One DALY represents the loss of one year of equivalent: full health. DALY = YLL + YLD