Disease management at the system level--an effective way to improve health care

The disease management approach to improving health care, at the system as well as the hospital level, has proved to be very powerful, producing unprecedented results in reducing costs while improving quality of care and patient satisfaction. The Boston Consulting Group (BCG), working with a variety of leading managed care providers and pharmaceutical clients, has pioneered the development and dissemination of the disease management concept. Defines the disease management approach and outlines how it differs from the traditional component management approach. Also describes the key elements of disease management, characteristics to look for in a candidate disease, and results achieved so far. Finally, discusses the three strategic roles a healthcare player can take in disease management.     

A strategic approach for managing conflict in hospitals: responding to the Joint Commission leadership standard, Part 1

BACKGROUND: The Joint Commission's leadership standard for conflict management in hospitals, LD.02.04.01, states, "The hospital manages conflict between leadership groups to protect the quality and safety of care." This standard is one of numerous standards and alerts issued by The Joint Commission that address conflict and communication. They underscore the significant impact of relational dynamics on patient safety and quality of care and the critical need for a strategic approach to conflict in health care organizations. Whether leadership conflicts openly threaten a major disruption of hospital operations or whether unresolved conflicts lurk beneath the surface of daily interactions, unaddressed conflict can undermine a hospital's efforts to ensure safe, high-quality patient care. DEVELOPING A STRATEGIC APPROACH TO CONFLICT MANAGEMENT: How leaders manage organizational conflict has a significant impact on achieving strategic objectives. Aligning conflict management approaches with quality and safety goals is the first step in adopting a strategic approach to conflict management. A strategic approach goes beyond reducing costs of litigation or improving grievance processes--it integrates a collaborative mind-set and individual conflict competency with nonadversarial processes. UNDERTAKING A CONFLICT ASSESSMENT: Conflict assessment should determine how conflicts are handled among the leaders at the hospital, the degree of conflict competence already present among the leaders, where the most significant conflicts occur, and how leaders think a conflict management system might work for them. CONCLUSIONS: Strategically aligning a conflict management approach that addresses conflict among leadership groups as a means of protecting the quality and safety of patient care is at the heart of LD.02.04.01.     

Ways to improve the management of hospitals

The article "Ways of improving the management of in-patient facilities" examines the organizational structure of management in respect to hospitals. A systems approach is used for management analysis. A hospital facility is defined as an hierarchical multilevel system of management. In this connection some problems concerning hospital management are considered: the multi-level character of management system, the specificity of management at each echelon of decision making process, the development of curative and diagnostic process technology, the problem of assessing management effectiveness at each hierarchical level. Attention is given to the training of hospital staff. Ways of improving the management of hospitals are determined for the purpose of raising the quality and effectiveness of in-patient care.     

Alzheimer''s disease in the United Kingdom: developing patient and carer support strategies to encourage care in the community.

Alzheimer's disease is a growing challenge for care providers and purchasers. With the shift away from the provision of long term institutional care in most developed countries, there is a growing tendency for patients with Alzheimer's disease to be cared for at home. In the United Kingdom, this change of direction contrasts with the policies of the 1980s and 90s which focused more attention on controlling costs than on assessment of the needs of the patient and carer and patient management. In recent years, the resources available for management of Alzheimer's disease have focused on institutional care, coupled with drug treatment to control difficult behaviour as the disease progresses. For these reasons, the current system has led to crisis management rather than preventive support--that is, long term care for a few rather than assistance in the home before the crises occur and institutional care is needed. Despite recent innovations in the care of patients with Alzheimer's disease, the nature of the support that patients and carers receive is poorly defined and sometimes inadequate. As a result of the shift towards care in the community, the informal carer occupies an increasingly central role in the care of these patients and the issue of how the best quality of care may be defined and delivered is an issue which is now ripe for review. The objective of this paper is to redefine the type of support that patients and carers should receive so that the disease can be managed more effectively in the community. The needs of patients with Alzheimer's disease and their carers are many and this should be taken into account in defining the quality and structure of healthcare support. This paper shows how new initiatives, combined with recently available symptomatic drug treatment, can allow patients with Alzheimer's disease to be maintained at home for longer. This will have the dual impact of raising the quality of care for patients and improving the quality of life for their carers. Moreover, maintaining patients in a home environment will tend to limit public and private expenditure on institutional care due to a possible delay in the need for it.     

Implementing Disease Management Programmes within an Integrated Delivery System

Implementation of disease management programmes within an integrated delivery system (IDS) requires a multipronged approach utilising education, process changes, tools and communication to overcome barriers. Implementation efforts should be directed toward every member of the staff who comes in contact with the patient, not just the physician.Successful implementation of disease management programmes using the above approaches has made it easy for those within the Lovelace Health System IDS to do the ‘right things’ for and by the patient. In this IDS, processes are embedded and transparent. Clinical data are presented at a patient level and are actionable. The horizontal and vertical integration of this IDS has facilitated the relative ease of disease management programme implementation. Combining the financial and clinical arms of the organisation as well as the presence of primary care and specialty care under one organisation has fostered degrees of collaboration not seen in most communities and has improved both processes and outcomes of care.     

Teaching information management

Managing in the present chaotic hospital financing environment requires integrated clinical/financial data systems and people who know how to use them. Health care management students of the present and future will need to understand how these information systems are structured and used. This article describes a graduate course in integrated clinical/financial information management as it has evolved at Yale University. The course provides students a vicarious experience in information management through class sessions and exercises using a database of real patient and cost center level information. Health care management of the future will depend on interdisciplinary collaboration and partnerships in education between provider organizations and academic programs. Both are modeled in the course.     

Readmissions After Hospital Discharge With Acute Exacerbation of COPD: Are We Missing Something?

Abstract

Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is an important part of the disease's morbidity, mortality, and progression, and is associated with increasing utilization of health care resources. The concept of integrated care based on a chronic care model is relatively new to chronic obstructive pulmonary disease, but has proved successful in improving clinical outcomes and probably in decreasing health care utilization in other chronic conditions. A comprehensive approach is needed to target a change in behavioral patterns in patients, increase physician's awareness and adherence to evidence-based recommendations, and address system related issues. This article discusses the evidence for various facets of nonpharmacological management of AECOPD and proposes a model of care that might be the missing link for reducing hospital readmissions for AECOPD. This model may decrease the morbidity, slow disease progression, and curb the increasing health care resource utilization without compromising patient care.     

One hundred years of the Association of Surgeons in the Netherlands. VIII. Surgical oncology

The Dutch surgical oncologists founded the Dutch Society for Surgical Oncology in 1981 with the aim of providing the best possible level of expertise in the multidisciplinary approach to the treatment of cancer, which at that time was a new development in cancer care. Since then, many developments have contributed to improving the outcome of care for the patient suffering from malignant disease. Surgeons have often played an initiating and pivotal role in these developments. Furthermore, in recent years there has been a strong development in quality awareness. This has led to a greater degree of cooperation in which intensive contacts exist. At the same time developments have taken place in surgical oncology: the care provided has developed from a broadly based care of the patient with a malignancy to care system concentrating on organ systems. As a result of this, the multidisciplinary therapeutic approach to the patient with cancer has been further developed. This might however lead to a fragmentation of oncological care and a loss of identity for the surgical oncologist, who possibly more than any other sub-specialist plays a pivotal role in caring for the patient with a solid malignancy.     

Hyperemesis gravidarum: an approach to the nutritional aspects of care

There has been little documentation on how to care for the patient with hyperemesis gravidarum. This article presents one method for managing patients with severe hyperemesis gravidarum in the hospital. At MacDonald House of University Hospitals of Cleveland, this method has been used quite successfully for the last five years. The combination of team support, individualized care, supplements created by the dietitian on the basis of patient preferences, and an adapted documented approach for patients with eating aberrations are important aspects of effective management of hyperemesis gravidarum.     

Physician partnerships: The value of clinical effectiveness resource management

Once perceived as a hospital‐only process, risk management is now recognized as an important part of clinical decision‐making and hospital operations. The greatest opportunities exist where risk management programs can be integrated into the development and implementation of guidelines, protocols and order sets that encourage adherence to valid clinical evidence and reduce unwarranted clinical variation in patient care. The limiting factors in this approach are providing the data needed to demonstrate the need for change and engaging administrators and clinicians in the development and implementation of those changes. This article describes a process for the development of hospital‐specific data that can be used to evaluate the cost impact of various decisions about patterns of care — the Clinical Effectiveness Initiative? — in this case used to demonstrate the cost impact of a choice between two medications used to prevent and treat a common disorder, venous thrombosis. It also describes how this data can be used to engage clinicians and administrators in a partnership focused on improving outcomes and patient safety by considering the full complement of factors — clinical, operational and risk management‐related — that contribute to those costs and outcomes. This process is clinical effectiveness resource management.     

Turning around an ailing district hospital: a realist evaluation of strategic changes at Ho Municipal Hospital (Ghana)

Background  

There is a growing consensus that linear approaches to improving the performance of health workers and health care organisations may only obtain short-term results. An alternative approach premised on the principle of human resource management described as a form of 'High commitment management', builds upon a bundles of balanced practices. This has been shown to contribute to better organisational performance. This paper illustrates an intervention and outcome of high commitment management (HiCom) at an urban hospital in Ghana. Few studies have shown how HiCom management might contribute to better performance of health services and in particular of hospitals in low and middle-income settings.     

Measuring the quality of hospital tuberculosis services: a prospective study in four Zimbabwe hospitals.

OBJECTIVE: To show how the use of a prospective approach to measuring the quality of services for a specific diagnosis can generate useful information for improving the quality of services in environments with limited information technology and data. DESIGN: Tracer approach focusing on intensive treatment of tuberculosis in hospital. The study was conducted in Zimbabwe in 1999. Local tuberculosis management guidelines were first translated into explicit quality assessment criteria and a panel of public health experts assisted in weighting different factors (structural and process) of the criteria. Factor weightings were based on both local knowledge and experience, and potential contribution of a factor to the likelihood of a positive outcome. A total of 138 patients was recruited into the study cohort at admission and followed up to discharge. An assessment of what was done to and for the patient was made for the entire hospitalization episode using explicit criteria. Comparisons were made between actual and maximum performance scores. SETTING: The study was conducted at four regional referral hospitals. The hospitals serve at least six secondary hospitals, and several public and private primary care facilities. The hospitals have a dual role as they also provide secondary care to their immediate catchment population. RESULTS: Notable quality gaps are observed between actual and maximum quality levels in all four hospitals although the size of the gap differed significantly. Variation in the quality of services between the hospitals is explained by distinguishable differences in structural and process aspects of tuberculosis management. CONCLUSIONS: It is feasible to conduct prospective quality assessment in developing countries with minimal disruption of routine activities. The study also showed that prospective exploration of health care quality for a specific diagnosis can provide insights into hospital-level quality issues. Such information is useful for monitoring and improving the quality of hospital services in general.     

JCI评审标准在医院感染管理中的应用

为提高医疗服务质量,保证患者安全,探讨加强医院感染管理的新思路.引入JCI医院评审标准中有关医院感染的标准.结合本院医院感染管理的实际情况,对照标准建立医院感染管理质量体系,完善组织结构,加强人员管理和培训、信息管理等方面进行了探索.旨在借鉴JCI评审标准,促进本院医院感染管理水平,使医疗质量和安全得到不断改进与提高.     

General practice - engaging the online social networking revolution

Current Australian health, hospital and primary care reforms, emphasise e-health strategies, including online communities and the electronic Person Controlled Health Record (ePCHR), as a means to improving patient support and self management of chronic disease. However, the benefits and risks of these tools to general practice are poorly understood.     

Theory-based telehealth and patient empowerment

Health care technology holds great potential to improve the quality of health care delivery. One effective technology is remote patient monitoring, whereby patient data, such as vital signs or symptom reports, are captured from home monitoring devices and transmitted to health care professionals for review. The use of remote patient monitoring, often referred to as telehealth, has been widely adopted by health care providers, particularly home care agencies. Most agencies have invested in telehealth to facilitate the early identification of disease exacerbation, particularly for patients with chronic diseases such as heart failure and diabetes. This technology has been successfully harnessed by agencies to reduce rehospitalization rates through remote data interpretation and the provision of timely interventions. We propose that the use of telehealth by home care agencies and other health care providers be expanded to empower patients and promote disease self-management with resultant improved health care outcomes. This article describes how remote monitoring, in combination with the application of salient adult learning and cognitive behavioral theories and applied to telehealth care delivery and practice, can promote improved patient self-efficacy with disease management. We present theories applicable for improving health-related behaviors and illustrate how theory-based practices can be implemented in the field of home care. Home care teams that deliver theory-based telehealth function as valuable partners to physicians and hospitals in an integrated health care delivery system.     

How have casemix,cost and hospital stay of inpatients in the last year of life changed over the past decade? Evidence from Italy

Healthcare utilisation and expenditure are highly concentrated in hospital inpatient services, in particular in end-of-life care with the peak occurring in the very last year of life, regardless of patient age. Few scientific studies have investigated hospital costs and stays of patients at the end of life, and even fewer studies have analysed their evolution over time. In this paper, we exploit hospitalisation data for the Lombardy region of Italy with the aim of studying the evolution of hospital casemix, costs and stays of chronic patients, and compare the last year of life of two cohorts of patients who died in 2005 and 2014. Despite an overall three-year increase in the age at death, the results showed a significant decrease in hospital costs and use due to reduced interventions and length of hospital stays. However, this was not associated with an increase in quality of life/conditions (as indicated by clinical casemix as a proxy) for end-of-life patients; patients’ casemix characteristics and clinical condition, as measured by the number of comorbidities, disease severity, prevalence of pulmonary disease and heart failure diagnosis, significantly worsened over the decade. This gives rise to important health policy concerns on how to identify effective policies and possible changes in healthcare system organisation to move from hospital-centred care to a community-centred approach whose value has been demonstrated during the COVID-19 pandemic.     

社区家庭医生管理高血压患者效果研究

目的 研究分析社区家庭医生制度实施1年后高血压患者管理的效果,探寻社区高血压病患者血压有效控制的医护模式.方法 选取我社区管辖内的146例高血压患者,依据患者自身意愿将其分为干预组（病患与社区卫生服务中心签订家庭医生服务协议并进行家庭医生高血压管理）与对照组（没有意愿与社区卫生服务中心签订家庭医生服务协议,进行传统社区高血压管理）各73例,对比分析两组患者1年后的高血压理论知识、自我管理能力、血压控制水平和治疗依从性结果数据.结果 干预组患者收缩压与舒张压明显低于对照组,血压控制良好.干预组患者对于高血压诊断标准、高血压危害和高血压治疗与预防等知识的知晓率高于对照组.干预组患者心理调整、合理运动、饮食调整、规律用药、监测血压和定期复查等自我管理能力和治疗依从性各项指标高于对照组.两组患者结果数据对比差异有较强显著性,具有统计学意义（P＜0.05）.结论 实施家庭医生管理高血压患者的医护模式能够提高病患理论知识、自我管理能力和治疗依从性,有效控制患者的血压,提升其生活质量.     

提高基层妇幼保健院药事管理水平的探讨

目的：探讨如何进一步提高基层妇幼保健院药事管理水平。方法：以县级妇幼保健院药事管理工作的内在要求和意义为基础,分析药事管理工作的内涵、医改背景下加强县级妇幼保健院药事管理的意义以及现阶段药事管理工作面临的困难和问题等诸多要素,并就如何提升县级妇幼保健院药事管理工作水平阐述自己的观点。结果：县级妇幼保健院围绕医改的新形势、新要求持续改进,做好药事管理工作。结论：医改的新形势要求县级妇幼保健院须不断的完善自身建设,促进医院药事管理水平和服务质量的不断提高。     

Clinical governance and operations management methodologies

The clinical governance mechanism, introduced since 1998 in the UK National Health Service (NHS), aims to deliver high quality care with efficient, effective and cost-effective patient services. Scally and Donaldson recognised that new approaches are needed, and operations management techniques comprise potentially powerful methodologies in understanding the process of care, which can be applied both within and across professional boundaries. This paper summarises four studies in hospital Trusts which took approaches to improving process that were different from and less structured than business process re-engineering (BPR). The problems were then amenable to change at a relatively low cost and short timescale, producing significant improvement to patient care. This less structured approach to operations management avoided incurring overhead costs of large scale and costly change such as new information technology (IT) systems. The most successful changes were brought about by formal tools to control quantity, content and timing of changes.