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Changing HealthCare System

Many of us who have had opportunities to make a difference soon realise that enterprise level and managerial support are needed to a great extent. Ultimately the goal of health services managers is to help maintain and enhance the health of the public. While individual citizens hold primary responsibility for their health status, there is much that health services managers working in concert with physicians, nurses, other health professionals, and community leaders can do to assist in the process.
This goal may seem strange to some and unrealistic to others. After all, isn’t it sufficient simply to care for those who come to you for help and make sure that one’s organisation retains its financial health in order to provide the requested care? The answer is no. Economic, political, and social forces have moved the health services system beyond the largely reactive acute care paradigm to a more holistic paradigm emphasising population-based wellness.

Some of the major economic, political, and social forces and their management implications that will influence healthcare delivery in the next five to ten years are:

•Financial incentives (government allocations) that reward superior performance; need for in- creased efficiency, productivity and quality; redesign of patient care delivery; development of strategic alliances that add value; increased growth of networks, systems and physician groups; increased accountability for performance;

•Information systems that facilitate patient-centred care across episodes of illness and “pathways of wellness;” effective implementation of clinical practice guidelines and related care management processes; ability to demonstrate continuous improvements of all functions and processes;

•Technological advances in the biological and clinical sciences; expansion of the continuum of care, need for new treat- ment sites to accommodate new treatment modalities; increased capacity to manage care across organisational boundaries; need to confront new ethical dilemmas; aging of the population and an associated increase in chronic illness;

•Increased demand for primary care, wellness, and health promotion services, and chronic care management; challenge of managing ethical issues associated with prolongation of life; increased ethnic and cultural diver- sity in the population; greater difficulty in understanding and meeting patient expectations;

• Meeting the challenge of eliminating disparities in care provision and outcomes; challenge of managing an increasingly diverse health services workforce; changes in the supply and education of health professionals; need for creative approaches in meeting the population’s need for disease prevention, health promo- tion, and chronic care management services;

•Need to compensate for shortages in some categories of health professionals (ie, physical therapy, pharmacy, and some areas of nursing); need to develop effective teams of caregivers across multiple treatment sites; need to develop work settings conducive to recruitment and retention; social morbidity (Aids, drugs, violence, bioterrorism, “new surprises”);

•Ability to deal with unpredictable increases in demand; need for increased social support systems and chronic care management; need to work effectively with public health community agencies to address “preparedness” issues; training the healthcare workforce in new informa- tion technologies;

•Increased ability to co-ordinate care across sites; challenge of managing an increased pace of change due to more rapid information transfer; challenge of dealing with confidentiality issues associated with new information technologies; globalisa- tion and expansion of the world economy; need to manage cross-national and cross-cultural patient care referrals;

•Increasing the competitiveness and productivity of the T&T labour force; managing global strategic alliances, particularly in the areas of biotechnology and new technology development; meeting the challenge of new and re-emerging infectious diseases.

These are not just local forces but regional and global. These forces have put pressure on our healthcare systems. Now more than ever, extremely good management practices are needed in healthcare delivery. Healthcare managers and professionals in T&T must now recognise that we live in a much different world. There are forces that are exerting pressure on our healthcare delivery systems. There are management implications arising out of these forces that must be noted. These forces were outlined above. These forces are causing a fundamental shift in the way in which healthcare is viewed. At the core of this shift is the movement away from episodic treatment of acute illness events to the provision of a co-ordinated continuum of services that will support those with chronic illness and enhance the health status of defined populations. In the evolving healthcare system of financial incentives for performance, organisations win by helping healthcare professionals provide services at that point in the continuum of care where the greatest value (ie, cost-benefit) is provided. They do not win by filling hospital beds or continuing to have key professionals working at cross purposes with each other.

These kinds of changes require new and different ways of organising and managing healthcare services. In its seminal work on Crossing the Quality Chasm, the Institute of Medicine identified six essential aims for any healthcare system: Safe—patients should receive care and be cared for in an environment that protects them from harm. Effective—care should be provided based on the best scientific information available and services not likely to benefit patients should be avoided. Patient-centred—care should take into account for individual patient preferences, needs, and values. Timely—care should be delivered expeditiously to meet patient needs with the elimination of waiting time and harmful delays. Efficient—care should be provided in a manner that avoids all waste—of equipment, supplies, ideas, and energy. Equitable—care should not vary because of personal characteristics such as gender, ethnicity, geogra-phic location, or socioeconomic status.

Achieving these six aims will require considerable leadership in addition to alignment of incentives among individuals, healthcare teams, health organisations, and the purchasers, payers, and regulators of healthcare services. The desired outcomes of safety, effectiveness, efficiency, personalisation of care, timeliness of care, and equitable care are most immediately a function of high-performing patient-centred teams operating within an organisation designed to facilitate the work of those teams. This is referred to as the “care system.” It is suggested that developing such care systems will require six major redesign imperatives including: Redesigning care processes themselves; making effective use of information technologies; developing the organisation’s knowledge and skills management capabilities including the ability to transfer knowledge quickly; developing effective teams; developing the ability to co-ordinate care across patient conditions, services, and settings over time; using performance and outcome measurements for continuous quality improvement and accountability purposes. All of this takes place within a payment and/or regulatory environment that will require greater incentives for organisations and the healthcare teams working within them to make the desired changes to improve care.

Dr. Stephen Ramroop
Former Medical Director SFGH


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