Organization of medicare

ORGANIZATION OF MEDICARE. SECONDARY AND TERTIARY MEDICAL AND SANITARY AID

Health is the biggest society and individual value, because it to a great extent influences processes and results of economic, social and cultural development of the country, demographic situation and state of national safety ness, it is the important social criterion of the degree of development and prosperity of society.

During today’s lecture we shall characterize the following states of giving Medicare to the population, which need difficult and special approaches.

So, according to the WHPO, secondary Medicare is the aid, that needs the service of the special character, more refined and difficult, than the aid, which is given by a general practitioner; includes the aid that is given by the specialized services according to direction of primary branches of medical service.

In „The bases of Ukrainian legislation of health care” the secondary Medicare is interpreted, as the specialized treatment-prophylactic aid that is given by doctors that have the proper specialization and can provide more skilled consultation, diagnostics, prophylaxis and treatment, than general practitioners.

Such a difference in the interpretation of the secondary Medicare in „The bases of Ukrainian legislation” and WHPO is explained by the fact, the quantity of the general practice doctors and family doctors is not enough yet, theraputists are wordily in the primary branch mainly.

The secondary Medicare in towns is provided by the city many-types incorporated hospitals and medical sections, in villages there are central district and district hospitals.

City hospitals provide about the third part of given Medicare.

Greater part of the city station establishments is united with policlinics, but the independent specialized hospitals also exist.

The main tasks of city hospital are:

– giving of the specialized round-the-clock stationary aid in a sufficient quantity;

– approbation and introduction  of modern methods of diagnostics, treatment and prophylaxis;

– complex treatment;

– examination of disabled;

– hygienically education of population.

The power of hospital establishment is determined by the number of existing beds.

Depending on the number of beds we can determine the staff of different services of doctors, middle medical personnel.

For the giving of the secondary Medicare to the urban population by the order of MPO of Ukraine № 33 from 23.02.2000 year the posts of personnel are set depending on the number of beds.

The number of beds for a 1 wage of a doctor hesitates from 12 (hematological) to 40 (tubercular, for patients with osteoarticular tuberculosis).

Let’s consider some shortly:

15 beds for 1 wage of a doctor are characterized for obstetric (accoucheurs-gynaecologists), allergists, cardiology (department of heart attacks), neurological department for neurologists, doctors-neuro-surgeons, surgeons.

20 beds for 1 wage of a doctor – gynecological gastroenterology, infectious, neurological, oncologic, orthopedic-traumatology, otorunnolaryngology, ophthalmology.

Except of the basic specialists the posts of doctors of other specialities are additionally entered in some departments (ieurological for patients with violation of cerebral circulation of blood is 1 post of doctor-internist for 60 beds, in proctological – 0,5 wage of doctor-oncologist).

The post of diagnostic and medically-auxiliary services, roentgenologists, endoscopists, laboratory assistants, doctors-physiotherapy and other are also set.

Depending on the number of beds in the department, the posts of managers of department are set:

– 60 (9 types is therapeutic, neurological, surgical, cardiologic, traumatological);

 – 50 (6 types is cardiac surgery, dermatovenereological, tubercular);

– 40 (14 types is gastroenterology, cardiologic and other);

– 25 (3 types – thoracic-surgery, obstetric, observative, pathologies of pregnancy).

Posts of the middle medical personnel depend on the number of beds and system of service for patients (two-three leveled).

At the three-leveled system  doctor, middle and junior medical personnel are involved.

At the two-leveled system  doctor and middle medical personnel.

24 hours’ sisterly post  is set: at least – 10 beds at  the three–leveled and 8 beds at the two-leveled  system in the infectious box department and for patients with neuro-infections.

Maximal number of beds – 40 at the three–leveled  system and 30 at the  two-leveled system in dermatovereological, endocrinology, tubercular-pulmonary departments.

Except of chamber, the following posts of such nurses are set:

–         operating-room;

–         bandaging;

–         of the dietary feeding;

–         medical sister for organization of individual care of seriously sacking;

–         procedural cabinet;

–         physiotherapy, massage.

Shortly we shall consider the structure of establishment of city hospital:

Rhythmical of working of establishment, substantiation of hospitalization, distributing of patients according to the type largely depends on the induction centre.

The induction centre can be centralized, that is the only one station for all establishment, and decentralized. In the first case it provides the structural distributing of patients through all the hospital, in the second – to the separate departments (infectious, obstetric, gynecological).

The induction centre provides the order of direction to permanent establishment and conducts:

–         registration of patients, that come to permanent establishment and leave it, filling the passport part of the in-patient card;

–         establishing of diagnosis;

–         substantiation of hospitalizations;

–         giving the urgent (aid) aid if it is necessary;

–         sanitary treatment;

–         taking the material for laboratory researches, express-diagnostics, roentgen- and functional researches; determination of type of the specialized department;

–         registration of refusals in hospitalization with determination of reasons;

–         giving the additional information for the hospitalized patients.

To fulfill the work the staff of doctors and middle medical personnel is set.

In the induction centre a doctor get acquainted meets with the facts of medical documents, makes an examination, gives necessary urgent aid and sends a patient to the proper department.

Different specialized departments can exits in city hospitals; it depends on the power of the hospital, presence of doctors in the town, and on distributing of departments between city and district hospitals.

These are mainly: therapeutic, cardiologic, surgical, traumatological, otorunnolaryngological departments. The set of departments is not regulated by the legislation.

Every stationary department consists of chambers and other premises for medical and economic aim (operating block, bandaging, cabinet for manipulations, intern, cabinets of the Head of the department and of the senior nurse. In order to isolate pations in the infectious hospitals the boxes are prepared.

By the order № 303 MPO of Ukraine from October 8, 1997, in the establishments treating and prophylactic of the subsections of anesthesiology and reanimations must exist. They must include such services:

–         department of intensive therapy;

–         anesthetic group;

–         department of intensive therapy, which is strictly specialized.

A manager who is appointed according to the manning table heads the stationary department.

The department of rehabilitation is organized in some many-profiles (types) city hospitals. Such departments are needed at the strictly specialized Medicare that is called tertiary today.

The secondary specialized treatment-prophylactic aid to the rural population is given in district medical establishments.

The leading establishments are central district hospitals that also carry out a role of organizationally medical centers in organization and quality of giving the Medicare.

A Head of the CDH is the chief doctor, who is also the chief doctor of district. He carries out the common guidance of the health care he is responsible for organization of Medicare, for medically-diagnostic, prophylactic, administratively-economic and financial activity of the hospital.

Such assistants aid a the chief doctor:

–         in  medical part;

–         in medical service to population of the district;

–         in examination of temporal disabled when there are not less than 25 medical posts at the ambulatory reception;

–         in the protection maternity and childhood;

–         manager of policlinic.

Assistant of the chief doctor in medical part: directly manages the medically auxiliary and diagnostic departments of permanent establishment. He is responsible for organization and quality of medically-diagnostic process in permanent establishment, for conducting of registration documents, examination of temporal disabled, for observation of sanitary and epidemiological norms and rules, analyses the activity of subsections of permanent establishment.

Assistant of the chief doctor in examination of temporal disabled: is responsible for organization and realization of all measures for conducting an examination. He controls the substantiation and rightness of delivery and continuation of medical certificate, analyses morbidity with temporal disability at the enterprises attached to the policlinic and terms of delivery of medical certificate, and also studies the cases of divergences of examinational decisions of the MCC (Medical-consultative commission) and MSEC (Medical sanitary expert commission).

The chief medical sister of hospital is directly submitted to the chief doctor and his assistant of in medical part. She organizes and controls the work of middle and junior medical personnel, by the aid of the doctors she carries out the measures for raising of it’s qualification, heads the Council of medical sisters of the hospital, controls the rightness of registration, distributing and storaging of medicines, bandaging material.

The basic tasks of CDH are:

–         direct giving of primary ambulatory-policlinic aid to the population of district centre and attached area;

–         giving of the specialized ambulatory-policlinic aid to all the population of the district;

–         giving of the specialized stationary aid to all the population of the district;

–         providing quick and urgent Medicare to population;

–         introduction into the practice of the district’s TPE* of work modern methods and facilities of prophylaxis, diagnostics and treatment;

–         organization of consultative aid;

–         organizationally-methodical guidance of the work of all district’s TPE, and also control work of their activity;

–         development and introduction of measures which are directed to upgrade the quality of medical providing;

–         development, organization and realization of measures which can raise qualification of medical personnel; rational usage of medical personnel’s and materially-technical resources;

–         planning, financing and organization of the materially-technical support of the district’s health care establishments;

–    qualification raising of medical staff of the district and section TPE.

*TPE – treatment-prophylactic establishments

Sometimes often on the joint of large in territory and remote from a regional center the specialized inter-district departments are made (created) which give specialized aid, lead consultative reception of the sick peoples from attached  territories.

The informationally-analytic departments, which analyze the indices of health of population, indices of work of the TPE district, are created in each CDH. They plan and organize visits of specialists of rural areas for the consultative aid to the population and doctors; they organize treatment-prophylactic aid in a district. District (chief) specialists get busy of this work, duties of which are carried out by experienced doctors. Together with an analytical department they estimate numerous information about indices of health of the population.

Tertiary Medicare

WHPO gives to it such determination: it is the aid, that needs highly skilled service, which as a rule can be given only in the centers and hospitals which passed the proper specialization and are specially equipped to that aim.

According to the „Bases of Ukrainian legislation of health care” the tertiary medically-sanitary aid (MSA) is given by a doctor or a group of doctors who have the proper preparation in the field of diseases which are difficult for diagnostics and treatment, in the case of treatment of illnesses which need the special methods of diagnostics and treatment. And also with the purpose of establishment of diagnosis and conducting of treatment of diseases which are rarely met.

Regional medical establishments belong to the centers of tertiary Medicare in Ukraine. These are many type and specialized hospitals, specialized dispensaries, republican specialized centers of medical aid.

These establishments differ by much better material and technical providing and complication of structure and functions.

Two functions of these establishments are considered to be basic:

–         organizationally-methodical guidance of the secondary level of MSA;

–         giving to the patients highly skilled and strictly specialized Medicare.

Structure of establishments of tertiary MSA consists of administrative and executive branches.

An administrative brand includes a chief doctor, his assistants, chief accountant, managers of the specialized departments and services, which carry out the duties of supernumerary specialists which are responsible for development of the services in the region, chief medical sister, managers of the departments and services of establishments and their senior nurses.

Additional subsections are made of organizationally-methodical departments and cabinets, book-keeping, engineering service, library with the group of scientifical-medical information.

Consultative policlinic is the separate structural subsection of establishment of tertiary MSA. The narrow specialized departments of permanent establishment, auxiliary treatment-prophylactic subsections, clinical, biochemical and bacteriological laboratories, separations of functional diagnostics, path anatomical, physical therapy and radiological departments) are obligatory.

The departments of the planned and urgent Medicare are special services of the regional hospitals.

We will consider the task and functions of some subsections of the tertiary branch of MSA:

The consultative policlinic of regional hospital conducts:

–         giving of highly qualified consultative aid to the patients after directions of treatment-prophylactic establishments of the region;

–         engages in consultation highly skilled doctors-specialists of the hospital and other TPE, and also workers of research institutes and medical institutes;

–         Sends the conclusions of the results of consultations to TPE;

–         develops for the TPE region the order and demonstrations for direction of patients to the consultative policlinic;

–         organizes and conducts out of clinic consultations of doctors-specialists in districts, and also consultations by correspondence for the doctors of the region’s TPE;

–         conducts the systematic analysis of cases of disagreements of diagnoses between TPE, which have sent the patients to the consultation and consultative policlinic at the districts of the region ;

–         analyses the errors assumed by doctors TPE at the inspection and treatment of patients before directing them to the consultative policlinic;

–         it is responsible for the informational providing about the news of modern methods of treatment and diagnostics in districts and TPE of the region.

The department of urgent and planly-consultive aid is other important structural unit of the regional hospital. In its structure there is a 24-hour’s dispatcher service of reception and registration of calls from the hospitals of districts and cities of the region. The specialists of regional hospital and other TPE regions employees of higher medical institutes, research institutes are attracted, to the giving of urgent and planly-consultive aid on the agreement with the corresponding establishments and institutions. To engage into this work employees, the special order is given out at the Management of health care.

Doctor giving the necessary Medicare in the place, and in the case of necessity transports a patient to the regional center, and on some occasion outside a region to the corresponding TPE.

Both sanitary aviation and ground vehicle is used to that aim, depending on the state of patient, distance, meteorological conditions, season, time of the day.

The same department provides the delivery of necessary medical loads donor blood and its preparations, canned organs and tissue, medicines to the districts and cities in the case of necessity.

Organizationally-methodical work is conducted at the level of establishments of tertiary level. It consists of the following sections :

The network of the independent specialized establishments-dispensaries belongs to the specialized establishments tertiary Medicare.

A dispensary is an establishment, the ambulatory and stationary aid at the certain diseases appears in which (tuberculosis, venereal illnesses, psychical, endocrine diseases and other).

According to the ratified list of establishments of health care there are 11 types of type dispensaries in Ukraine.

Dispensaries consist of policlinic (clinical separation) and permanent establishment.

During the organization of work of these establishments the features of every dispensary are taken into account. They are determined by etiology, clinic, epidemiology of concrete diseases.

 

Principles of work of all dispensaries are equal and consist in:

–         active systematic supervision after contingents and giving the skilled Medicare;

–         supervising after contact people;

–         conducting of prophylactic measures and hygienical education of population;

–         studying of morbidity in the district of activity;

–         developing of preventing measures of against appearance of pathology;

–         giving of consultative aid to the doctors of other medical establishments;

–         controlling the completeness registration and on time signalization when a patient is revealed.

The medical card of out-patient and checking card of clinical supervision  are the basic registration documents in dispensaries.

The last of them aids to control the on time of visits, passing of medical examination, fulfilling of the appointed treatment, health measures and employment.

 

Now we will shortly describe the activity indices of permanent establishments, as the main branch of the secondary and tertiary medically-sanitary aid to the population, according to which the medical work is estimated. These indices  characterize:

–         guarantee to population the stationary aid;

–         the job of the medical personnel;

–         materially-technical support;

–         usage of bed fund;

–         quality of stationary Medicare and its efficiency.

Calculate:

1.     Average annual occupation of bed:

2.     Middle duration of the staying of a patient in a hospital:

3.     Circulation of bed (middle number of patients which were on a bed):

Indices are calculated for the whole permanent establishment, and also for all his departments.

Activity of doctors is calculated separately:

For example:

а) middle number of operations for one occupied post of surgeon:

4.     Index of lethality (it is calculated in %):

b) after operational lethality is determined separately:

The analysis of activity of medically-auxiliary subsections is conducted in relation to in-patients:

For example:

Activity of other subsections is estimated in the same way (MRT – therapy, x-ray photography of laboratory, laboratories and other).

However, speaking about the secondary and tertiary branches of medically-sanitary aid, it should be said, that for today even the tertiary level of Medicare occupies high enough percent, and exceeds the extent and tasks which stand before it. It is conditioned by that, medical establishments of tertiary level often carry out the functions of the secondary and even primary for in the habitants of regional center and nearest settlements. According to statistical information, up to 80 % visitors of consultative policlinic and 60 % of hospitalized are the habitants of regional center. It confirms the necessity of radical changes in organization of Medicare.

Two directions of structural rebuilding of stationary aid are offered for today, strategy of which consists in the solving of two connected tasks:

1) Diminishing of levels of hospitalization by substitution relatively expensive stationary treatment by more effective and economically advantageous types of Medicare;

2) Increasing of efficiency of the usage of bed fund.

І. The first task is necessary to decide by:

а) the improvement of on time and quality of primary medically-sanitary aid;

b) substitution of hospital aid by ambulatory as a result of application of modern effective pharmaceutical facilities;

c) widening of the system of home treatment, first of all patients of old years and invalids;

d) developing of alternative types of treatment as daily and home permanent establishments, ambulatory centers in surgery;

e) the increasing of threshold levels in hospitalization by organization of departments for the short-term supervision after patients in older to have a possibility to make a decision about hospitalization in doubtful cases.

ІІ. For the increasing of efficiency of the usage of bed fund is necessary:

1) conducting of structural transformations in the system of stationary aid, oriented on the increasing of functionality of the usage of bed fund and forming an optimal territorial network of stationary establishments;

2) change of the legal status of hospital;

3) introduction of the effective systems of financing of stationary aid;

4) improvement of integration between permanent establishments, primary and social.

Structural rebuilding of stationary sector includes:

– differentiation of bed fund in accordance with intensity of treatment and nursing;

– concentration of highly-specialized hi-tech aid;

– forming of common medical space and liquidation of the administration systems of medical service of some contingents of population.

Today we discussed the secondary and tertiary level of Medicare, and strictly define the size of the aid in city hospitals, district (ІІ level) and regional (ІІІ level) hospitals. However in practice a substantial difference between the ІІ and ІІІ level in Ukraine doesn’t exist.

According to the generally accepted criteria of observance of hierarchical of hospital aid, the high indices of turn of resources and short terms of staying of patients must be in the hospitals of the secondary level and long terms in the hospitals of tertiary level.

The existent index of the TPE II level testify about unsatisfactory organization and quality of treatment in the hospitals of such type, and relatively short terms of patients staying in regional hospitals that we can consider that greater part of their patients does not need treatment in establishments of such type.

To increase the efficiency of functioning the MPO of Ukraine plans to give to the hospitals the status of state enterprises with giving of them certain administrative and economic autonomy. It will give the possibility to decrease the number of limitations in activity of establishments, which are traditionally met at TPE.

The MPO plans to conduct reorganization and reformation of stationary aid in Ukraine in a few stages.

At that:

І. On the first stage to carry out:

–         development of the criteria (indices) of hospitalization and leaving of patients from stationary establishments (departments) of different intensity;

–         to define the optimum level of hospitalization in permanent establishments of intensive treatment, permanent establishments for treatment of chronic patients, hospital of sisterly nursing;

–         to define the necessities of population in hospital beds in accordance with the level of intensity of medical service;

–         it is necessary to review the table equipment and norms of loading of medical personnel, coming out of multilevel organization of stationary aid;

–         to conduct licensing of medical establishments independently of forms of ownership, with determination of those types of Medicare, for the giving of which they have corresponding conditions;

–         to develop the plans of gradual transition to the multilevel system of stationary service;

II. On the second stage it is necessary to take into account the factor of availability of stationary aid (character of settling, transporting availability), formed habits of population to the place of reception of services. Thus it is needed to foreseen:

–         gradual transmission in community property of administrative medical establishments;

–         territorial integration of hospitals of different subordination;

–         diminishment of number and strengthening of hospitals, the urgent stationary aid are given in which;

–         reorganization some of the hospital powers into establishments (departments) for chronic patients, establishments (departments) for giving of medically-sanitary aid – sisterly nursing and other.

–         concentration of hi-tech highly-specialized aid at regional level;

–         introduction of the system of the complete providing of quality of medical service; it is accreditation of hospitals, internal systems of control, clinical protocols;

–         development of services (social aid and increase of its availability), improvement of co-ordination between the sector of health care and social sector.

III. It is necessary on the third stage:

–         complete transition to the multilevel system of stationary service;

–         completion of forming of common medical space for giving of Medicare;

–          exposure of surplus hospital powers and establishments which do not complete modern standards and their next closing.