jandacva, jandacvis momsaxureba da xarisxi

2011

lopota

cnobili adamianebi sazogadoebrivi jandacvis Sesaxeb

“araferi ar SeiZleba iyos qveynisTvis imaze mniSvnelovani, vidre jandacvaa; qveynis umTavresi sazrunavi unda iyos misi xalxis janmrTeloba”

franklin d. ruzvelti

(In a report to the New York Legislature, 1931)

dRes visaubrebT1. xarisxTan dakavSirebuli problemebi jandacvis sistemaSi;2. ra aris samedicino Secdoma, Secdomis tipebi3. ra aris jandacvis xarisxi – ra aris pacientis usafrTxoeba4. xarisxis gansazRvrebebi5. xarisxTan dakavSirebuli problemebis analizi ekonomikuri kuTxiT6. mTavrobis roli jandacvis sistemaSi xarisxis uzrunvelsayofad7. xarisxis gasaumjobesebli miznebi 8. ra aqtivobebia saWiro xarisxis gasaumjobeseblad

anu jandacvis politika xarisxTan mimarTebaSi

ra aris janmrTeloba?

“sruli fizikuri, mentaluri da socialuri keTildReoba da ara ubralod

daavadebis an sisustis ararseboba”

(WHO Constitution)

janmrTelobios koncefciaMarc Lalonde

1. definicia – janmrTeloba es aris faqtorTa rezultati, romlebic asocirebuli arian genetikur memkvidreobasTan, garemosTan, individualur cxovrebis wesTan da samedicino momsaxurebasTan. janmrTeli cxovrebis xelSewyobas SeuZlia gaaumjobesos janmrTeloba da Seamciros samedicino momsaxurebis saWiroeba

2. elementebi – a. genetikuri da biologiuri faqtorebi; b. qceviTi (cxovrebis stili) faqtorebi; g. garemo (moicavs ekonomikur socialur da fizikur faqtorebs); d. jandacvis sistemebis organizacia

jandacva

jandacva es aris kerZo da saxelmwifo seqtorebis saSualebiT sruliad

sazogadoebis mcdeloba miRweul iqnas janmrTeloba

jandacvis sistemis amocanebi

• gaaumjobesos mosaxleobis janmrTelobis mdgomareoba;

• akontrolos jandacvis xarjebi;

• prioritetebis mixedviT gadaanawilos arsebuli resursebi;

• gaaumjobesos momsaxurebis xarisxi;

• gadaanawilos momsaxureba Tanabrad mosaxleobis yvela fenaze

mTavari amocana

uzrunvelyos mosaxleoba adeqvaturi samedicino momsaxurebiT

Aadeqvaturi samedicino momsaxureba

ras vgulisxmobT adeqvatur momsaxurebaSi?A

adeqvaturi Careva niSnavs, roca im maqsimaluri saSualebiT rac konkretul Carevas SeuZlia

miRebuli sargeblebi (gazrdili sicocxlis saS. xangrdzlivoba, tkivilis Semcireba fsiqo emociuri, sxva funqciuri gaumjobeseba) aRemateba mosalodnel negatiur

rezultatebs (sikvdiloba, avadoba, dakarguli samuSao saaTebi, tkivili da a. S)

Chassin MR, Park RE, Kahn KL, Kosecoff J

samedicino xarisxi

• The Institute of Medicine (IOM) -xarisxi romliTac jandacvis servisebi

Tanamedrove profesiuli codnis saSualebiT zrdis sasurveli Sedegebis miRwevis albaTobas

Department of Health (UK 1997)

jandacvis xarisxi aris:

• swori qmedebebi (ra)

• swor pirovnebebze (vis)

• swor dros (rodis)

• Dda swori qmedebebi pirvelive Carevisas

maRali xarisxis jandacvis politikis safuZvlebi

1. pacientcentruli momsaxureba;

2. adeqvaturi xelmisawvdomoba;

3. adeqvaturi samecniero codna;

4. kompetenturi jandacvis mimwodeblebi;

5. samedicino da finansuri gadawyvetilebebis gamijvna;

6. jandacvis sistemis swori organizacia (efeqtianoba, efeqturoba, swori sakanonmdeblo uzrunvelyofa);

jandacvis evolucia:

daavadebis mkurnalobidan jandacvamde

1980 1985 1990 1995 20001975 2005

xarjebis kontrolis era

xarjebis Semcirebisa da

utilizaciis kontrolis era

xarisxze orientirebuli medicinis era

ratom xarisxze orientirebuli era

xarisxi - kliSe

amerikis medicinis institutis moxseneba

im samedicino Secdomebis gamo, romelTa prevenciac SesaZlebeli iyo yovelwliurad

amerikaSi iRupeba ufro meti adamiani vidre Sidsisagan, ZuZus kibos an avtokatasrofebisagan

saSualod 98 000 – 100 000adamiani weliwadSi

IOM Report 1999.

samedicino Secdomebis zegavlena

• didi britaneTis jandacvis departaments 2000 wlis moxsenebaSi iTqva, rom ubeduri SemTxvevebi xdeba hospitalizirebuli pacientebis daaxloebiT 10 %-Si anu 850, 000 ubeduri SemTxveva wlis ganmavlobaSi.

• “xarisxi avstraliis jandacvis sistemaSi” kvlevis mixedviT (romelic gamoica 1995 wels) ubedur SemTxvevaTa sixSire hospitalizirebul pacientebSi 16.6 % Seadgens.

• The Hospitals for Europe’s Working Party on Quality Care in Hospitals daadgines, rom evropaSi 2000 wels yoveli meaTe hospitalizirebuli pacienti ziandeboda iseTi dazianebebisgan, romlis prevenciac SesaZlebeli iyo;

ra aris Secdoma

Secdoma aris dagegmili moqmedebis ar Sesruleba ise, rogorc winaswar iyo

gansazRvruli…an Sedegis misaRwevad arsowori gegmis

gamoyeneba

Secdomis tipebi

• aqtiuri

• latenturi

HealthGrades moxseneba - daskvna

• sikvdilobis umetesoba gamowveulia ara personalis arakompetenturobis, aramed sistemuri Secdomebis gamo

• adamiani yovelTvis uSvebs Secdomas ara aqvs mniSvneloba Tu rogori ganaTleba da momzadeba aqvs mas……

rogoria industriuli standarti Secdomebis dasaSvebi min. raodenoba

• A230 – ze naklebi (wuni, defeqti) 1 milion warmoebul produqtSi anu 0,023%

• 5 –ze naklebi yovel 1 milionSi Secdomebi dakavSirebuli finansuri servisebis tranzaqciebTan anu 0,0005 %

• ra xdeba jandacvaSi?

ra xdeba jandacvaSi

6,000 dan 300,000 mde xarvezi, yovel 1 mlnSi

Sesabamisad 0,6 – 30%

Source: Kohn, LT, Corrigan, JM, and Donaldson, MS (Eds).

ubedur SemTxvevaTa da SecdomaTa sixSire

370 sxva adgilas Catarebuli qirurgiuli operaciebis SemTxvevebi;

365 operaciuli/post-operaciuli garTulebebi;326 wamlismier SecdomebTan dakavSiebuli

SemTxvevebi;221 sikvdili dakavSirebuli mkurnalobis

dayovnebasTan;144 pacientis dacema/waqceva;124 sikvdiloba patimrobaSi myof pacientebs

Soris107 Zaladoba/gaupatiureba/mkvleloba85 gadasxmasTan dakavSirebuli movlenebi84 perinataluri sikvdiloba/dazianeba57 infeqciasTan dakavSirebuli movlenebi57 saavadmyofodan gaqcevis Semdgomi sikvdili51 xanZari49 anesTeziasTan dakavSirebuli movlenebi

erTiani komisiis mier ganxiluli 2966 ubeduri SemTxveva, ianvari 1995 - dekemberi 2004:

ubedur SemTxvevaTa adgili/dawesebuleba

ianvari 1995 – dekemberi 2004

0 200 400 600 800 1000 1200 1400 1600 1800 2000

Office-base surgery

Health care network

Critcal access hospital

Clinical laboratory

Home care service

Ambulatory care setting

Long term care facility

Emergency department

Psychiatric unit

Out-pt behavioral health

Psychiatric hospital

General hospital

Total for all settings = 2966

1942351

159

155

131

95

67

54

6

2

1

3

ubedur SemTxvevaTa ZiriTadi mizezebi

0 10 20 30 40 50 60 70 80 90 100

Organization culture

Care planning

Continuum of care

Leadership

Environ. safety / security

Procedural compliance

Competency/credentialing

Availability of info

Staffing

Patient assessment

Orientation/training

Communication

yvela kategoria; 1995-2004

Percent of 2966 events

sikvdilis SemTxvevebi drois erTeulSi - riskebi

• orsuloba 1• matarebliT mgzavroba 5• saxlSi muSaoba 8• soflis-meurneobis nawilSi muSaoba

10• • sacobSi yofna 50

• mSeneblobaze muSaoba 67• frena 100• hospitalizacia 2000

cudi xarisxis Rirebuleba

cudi xarisxis wliuri xarji saS. TiTo dazRveulze

• $1,500 pirdapiri jandacvis xarji

• $400 - $750 arapirdapiri xarji (mag gacdenili samuSao dReebi)

• $1,900 - $2,250 cudi xarisxis MmTliani jamuri saS. xarji

jandacvis da cudi xarisxiT gamowveuli xarjebis dinamika wlebis mixedviT

0,25

0,7

2,3

0,07

0,2

0,42

0,69

1,4

0

0,5

1

1,5

2

2,5

1980 1990 2001 2008

jandacvis xarjebi sul

cud xarisxTan asocirebuli xarjebi

cudi xarisxis efeqti Juran Institute, Inc.

The Severyn Group, Inc. 2007

problema efeqti

1 wamlebis araswored gamoyeneba 300 mlrd

2 antibiotikebis araswori daniSvna 5 mlrd

3 nozokomialuri infeqciebi 20-60,000 sikvdilis SemTxveva + 18 mlr

4 diabeti 132 mlrd

5 depresia 80 mlrd

6 araadekvaturad namkurnalebi gulis mwvave iSemiuri daavadebebis sikvdilobis SemTxveva yovelwliurad

18, 000 sikvdilis SemTxveva

7 arasworad marTuli gripisa da pnevmokokuri vaqcinacia

10,000 - 20,000 sikvdilis SemTxveva

8 asTmis cudi marTva 18 mlrd

9 gulis qronikuli iSemiuri daavadebebis uxarisxod marTva

10 – 40 mlrd

cudi xarisxis gamovlinebebi

• resursis zedmetad moxmareba

• resursis arasakmarisad gamoyeneba

• resursis arasworad gamoyeneba

resursis zedmetad gamoyeneba

• qirurgiuli procedurebi, testebi, samkurnalwamlo saSualebebi:

• mag: histereqtomiebi, kardiokaTeterizaciebi, timpanostomiebi, karotiduli endarteqtomiebi, kardialuri peismeikerebi, gstrointestinaluri endskopiebi, antibiotikebi, sedatiuri saSualebebi, arasteroiduli anTebis sawinaaRmdego saSualebebi

resursis zedmetad gamoyenebis mizezebi:

kvlevebi uCveneben

• zedmeti raodenobis hospitlebi – hospitaluri servisebis rigi procedurebisa da mkurnalobis zedmetad gamoyeneba,

• zedmeti raodenobiT eqimebis Tavmoyra garkveul regionSia aseve mizezia zedmeti moxmarebis da jandacvis xarjebis zrdis

resursis arasakmarisad gamoyenebis magaliTebi

• bevria faqtebi, rom eqimebi ar mihyvebian mtkicebulebebze dafuZnebul gaidlainebs da pacientebi ar iReben diagnostikur da Teerapiul servisebs, wamlebs da procedurebs iseTi daavadebebis dros rogorebicaa g.i.d da diabeti;

• gripis da pnevmokouri vaqcinebis administrireba;• skrining testebi depresiis, ZuZus kibos, qlamidiazis

dasadgenad

rac iwvevs sicocxlis xarisxis daqveiTebas da rig SemTxvevaSi sikvdils.

aseTi midgomebis zusti finansuri Sedegi ar aris naTeli

resursis araswori gamoyenebis magaliTebi

• samedicino Secdomebi yvelaze metad xdeba arasworad gamoyenebis dros:

• wamlebi;• nozokomialuri infeqciebi;• diagnostikuri da qirurgiuli Secdomebi;• samedicino aparaturis araswored

gamoyeneba

• erTi ver SesZlebs garantirebuli gaxados xarisxi – erTs SeuZlia mxolod gazardos albaToba, rom momsaxureba iqneba “kargi” an “ukeTesi”

• Avedis Donabediani

• saWiroa sistemuri midgoma

jandacvis xarisxis struqtura avedis donabedianis mixedviT

struqtura procesi Sedegi

kapitaluri Senobebi, aparatura,

saSualebebi trenirebuli samed. personali (eqimebi,

eqTnebi, administratorebi)

adekvaturi, efeqturi, eTikurad

relevantuli, koordinirebuli da

socialurad misaRebi

samedicino momsaxureba

sikvdiloba, avadoba, cxovrebis xarisxi,

pacientTa kmayofileba

sistemis maxasiaTeblebi Ppacientis maxasiaTeblebi

source: Hopkins: Measuring the quality of medical care, Royal College of Physicians of London, 1991

saxelmwifos roli

jandacvis Tavisufali (araregulirebadi) bazari

iwvevs uTanabrobas, gazrdil xarjebs

sazogadoebisaTvis da sabolood xarjebis zrdas

mTavrobisaTvis

kerZo seqtori kontrolis (regulaciis) gareSe ar iqneba farTo sazogadoebis interesebis dacvaze pasuxismgebeli

da

jandcvis bazari ar aris srulyofili da idealuri

Sesabamisad…

ra aris idealuri bazari?

• Zalaufleba Tanabaria• idealuri konkurencia da arCevani• sruli informacia• fasebi ar aris fiqsirebuli• gamWvirvalea Semsyidvelisa da

gamyidvelisaTvis

ratom aris jandacvis bazari arasrulyofili (idealuri)?

• urTierToba momxmarebelsa da mimwodebels Soris ar aris Tanabari

• mimwodebels gaaCnia meti informacia

• momxmarebeli ar aris srulad informirebuli

• momxmarebeli xSirad krizisSia da damokidebulia mimwodebelze

• alternatiuli miwodebis resursi xSirad ar aris SesaZlebeli

• mimwodeblebs xSirad SeuZliaT fasebis gayinva

• mesame piris gadamxdelis (dazRveva) stimulebi cvlis mimwodeblis da momxmareblis gadawyvetilebebs

ra unda gaakeTos qveyanam

pacientis usafrTxoebis mxriv ?

saxelmwifom xeli Seuwyos

usafrTxo sistemis Seqmnas

• Poka – Yok

• 6 Sigma

erovnuli nabijebi pacientis usafrTxoebis gaumjobesebisaTvis

• usafrTxoebaze fokusirebuli standartebis SemuSaveba

• Secdomebis Setyobinebis xelSewyoba• gamocdilebis gaziareba• riskis Semcireba prevenciis gziT• pacientebis usafrTxoebaSi CarTva• usafrTxoebis yovelwliuri miznebis

SemuSaveba• TavSeyra, TanamSromloba, ganaTleba

• imisaTvis, rom uzrunvelyos xarisxi jandacvis sistemaSi

• saxelmwifos erTerTi mTavaria funqciaa areguliros jandacvis bazari

sistemis martivi xedva

rogor gavaumjobesoT

rasac vakeTebT?

ratom vakeaTebT

rasac vakeTebT?

rogor vakeTebT

rasac vakeTebT

jandacvis regulacia

• 1970 iani wlebi mimowodeblis qcevis maregulirebeli decentralizirebuli programebi (jandacvis saagentoebi, saWiroebis serTifikatebi, biujetebi)

• 1980 iani wlebi metad centralizirebuli regulaciebi (peer review organizaciebi, samedicino praqtikis gaidleinebi) da biujetebi (medicare biujeti, prospeqtuli)

• gaZlierda qceviTi regulaciebis saxiT naklebad biujeturi regulaciebi

jandacvis regulacia II

• yvela dasavluri qveynebi aregulireben TavianT jandacvis sitemebs;

• yvela (amerikis garda) aRiarebs saWiroebas centraluri mTavrobis mier myari magram naTeli wesebis dawesebas Semsyidvelebis, mimwodeblebis da momxmareblebisTvis;

• yvelas esmis, rom mesame piris gadaxdisa da exstensiuri benefitebis kombinacia sxva SSesaZleblobas ar izleva.

jandacvis regulacia III

• umetesi dasavleTis qveynebi strategiul aqcents akeTeben biujetur regulaciebze (SeTanxmebuli fee eqimebTan, globaluri biujeti saavadmyofoebs. es sazogadoebebi naklebad arian damokidebuli qceviT regulaciebze

• qceviTi regulaciebi zemoqmedebs ekonomikur aqtivobebze da Sesabamisad biujetze, da biujeturi regulacia SesaZlebelia iyos efeqturi mxolod im SemTxvevaSi Tu is zemoqmedebas axdens qcevaze

• gansxvaveba aris intervenciis strategiaSi aseT SemTxvevaSi

• aSS –Si 1980 iani wlebidan gamoCnda biujeturi regulaciebi arsenali

• aris molodini, rom iqneba seriozuli cvlileba am mimarTulebiT

Tumca

P4P moqmedebaSia

maregulirebeli midgomebi

• licenzireba

• serTificireba

• akreditacia

Llicenzireba

mTavrobis mier marTuli savaldebulo programa, romelic moiTxovs, rom:

samedicino dawesebulebebi akmayofilebdnen minimalur samoqmedo standartebs

serTificireba

nebayoflobiTi samTavrobo an arasamTavrobo programa, romelic aRiarebs, rom:

samedicino dawesebulebebi akmayofileben garkveul standartebs specializirebul

mimarTulebaSi.

umetesad nebayoflobiTi procesi, romliTac samTavrobo da

arasamTavrobo organoebi aniWeben aRiarebas im samedicino

dawesebulebebs, romlebic akmayofileben garkveul

standartebs, romelic moiTxovs uwyvet struqturul, procesualur da

Sedegobriv ganviTarebas.

akreditacia

es aris moTxovnebi, romlebic gansazRvraven Sesrulebis

molodinebs struqturis, procesis da Sedegis gaTvalisiwnebiT. unda arsebobdes organizaciaSi, raTa

uzrunvelyofili iyos pacientis usafrTxoeba da movlis xarisxi.

standartebi

I. pacientcentruli momsaxureba

• pacientis/mosaxleobis (saWiroebebis Seswavla/gaTvaliswineba);

• pacientis uflebebis dacva;

• eqimis da pacientis urTierTobebis gaumjobeseba (imijis gamosworeba);

• pacientis ganaTleba

• momxmareblis maqsimaluri CarTva gadawyvetilebis miRebis procesSi

II. adeqvaturi xelmisawvdomoba;

• geografiuli;

• finansuri (bazisuri kalaTa);

• xarisxobrivi (adeqvaturi);

• Tanasworoba (eTnikuri, genderuli, profesiuli).

III. adeqvaturi samecniero codna;

• sarwmuno samecniero kvlevebis warmoeba;

• statistikuri meTodebis aqtiuri danergva samedicino sazogadoebaSi;

• sarwmuno literaturis gamoyeneba;

• samecniero mtkicebulebebze dafuZnebiT gadawyvetilebebis miRebis praqtika

IV. kompetenturi jandacvis mimwodeblebi;

• prediplomuri ganaTleba;

• postdiplomuri ganaTleba;

• licenzireba, akreditacia (dawesebulebebis);

• mimwodebelTa Sefasebis Tvladi kriteriumebis SemuSaveba;

• uwyveti samedicino da profesiuli ganaTleba;

• dawesebulebebis, medpersonalis optimizacia.

V. samedicino da finansuri gadawyvetilebebis gamijvna;

• samedicino dawesebulebaTa da med. personalis dafinansebis gamarTuli politikis SemuSaveba;

• swori motivaciuri sistemis SemuSaveba;

• klinikuri da kliniko-ekonomikuri standartebis Camoyalibeba

VI. jandacvis sistemis swori organizacia (efeqtianoba,

efeqturoba);• axali struqturuli erTeulis Camoyalibeba

• saxelmwifo, naxevrad saxelmwifo Tu decentralizebuli modelebis ganxilva;

• multiseqtoraluri kolaboraciis uzrunvelyofa;

• mkafiod gansazRvruli pasuxismgeblobebis Camoyalibeba;

• samedicino momsaxurebis balansireba pirvelad moereul da mesameul rgolebs Soris;

• marTvis informaciuli sitemebi;

• adeqvaturi mmarTvelobiTi gundebiT samedicino dawesebulebaTa uzrunvelyofa;

• samecniero mtkicebulebebze dafuZnebuli marTvis praqtika

xarisxis gaumjobesebis meTodebi modeli I

finansuri stimulireba:

1.1 pirdapiri finansuri stimulebi mimwodebels kargi xarisxisTvis

1.2 rogorc saukeTeso mimwodeblis saxalxo aRiareba

1.3 momxmareblis finasuri stimulireba ukeTesi xarisxis arCevisaTvis

1.4 xarisxTan dakavSirebuli aqtivobebis subsidireba

modeli #2

seleqtiuri kontraqtireba saukeTeso maCveneblebis mqone mimwodebelTan

2.1 kontraqtiT gansazRvruli ufleba movaleobebi

2.2 Sesrulebis kriteriumebis danergva2.3 saukeTeso centrebis aRiareba – referens

centrebad qceva, seleqtiuri kontraqtireba

modeli #3

regulirebis sxva saSualebebi,

3.1 mimwodebelTa qcevis regulacia (licenzireba uwyveti samedicino ganaTlebisa da profesiuli ganviTarebis CarTviT). Tanamedrove klinikuri gaidlainebisa da protokolebis danergva;

3.2 struqturis gaumjobesebis xelSewyoba, dawesebulebaTa gamkacrebuli standartebis da axali kriteriumebis danergviT

3.3 procesis xelSewyoba akreditaciis procesis danergviT

gamWvirvaloba

sikvdiloba saavadmyofoebis mixedviT

saavadmyofoSi Semobrunebis maCvenebeli

barZayis motexilobis gaTuleba

sakeisro kveTa saavadmyofoebis mixedviT

instruqciebi gawerisas

Tambaqos sawinaaRmdego kampania saavadmyofoSi

didi madloba