Hospital Services & Management

Hospital Services and Management

Nawanan Theera-Ampornpunt, MD, PhDFaculty of Medicine Ramathibodi Hospital, Mahidol University, Thailand

Modified from slides of Assoc.Prof. Artit Ungkanont

Parts of this material were based on materials developed by Johns Hopkins University, funded by the Office of the National Coordinator for Health Information Technology, U.S. Department of Health and Human Services under Award

Number IU24OC000013 (Health IT Workforce Curriculum v.2.0, Component 7/Units 2-3).

A Bit About Myself2003 M.D. (Ramathibodi)2009 M.S. in Health Informatics (U of MN)2011 Ph.D. in Health Informatics (U of MN)

Medical Systems AnalystHealth Informatics DivisionFaculty of Medicine Ramathibodi HospitalMahidol [email protected] www.SlideShare.net/Nawanan

Research interests:• Health IT applications in clinical settings (including EHRs)• Health IT “adoption”• Health informatics education

Outline

• Overview of the healthcare system• Hospitals as a key component• Nature of hospital services• Contrast with ambulatory & emergency settings• Management of hospital operations• Needs for health IT in hospitals• Conclusion

The Healthcare System

Hospital A Hospital B

Clinic C

Government

Lab Patient at Home

Stakeholders in Health Care

Patients

Providers

Policy-Makers

Public

Payers

• High bargaining power• Want to pay less money for more quality

• Want to deliver the best outcomes to patients with limited resources• Needs to satisfy many “bosses”

• Want data for policy-making and management• Limited budget• Often face bureaucracies• Highly political

• Concerns about resource allocation & community’s well-being, but not necessarily individual patients

• Want a high-quality care and satisfactory service experience for an acceptable cost

Providers

• Provide health care services to patients• Hire or employ health care professionals, including

physicians, nurses, pharmacists, etc.• Receive payment from patients or third-party

payers– National Health Security Office– Social Security Office– Comptroller-General Department– Private insurance companies

Providers in Thailand’s Various Settings

• Ambulatory Setting– Private clinics (sometimes called physician’s offices)– Outpatient departments of hospitals– Private pharmacies– Dental clinics– MOPH’s community health centers

• Currently called “health promotion hospitals”• They are not really hospitals!! Just a political marketing tool!


• Emergency Setting– Emergency rooms of hospitals– Ambulances and pre-hospital care– Incident management and command


• Inpatient Setting– Inpatient wards for

• Acute care hospitals• Nursing homes (for the elderly and chronic patients)• Hospice (for the terminally ills)

– Special cases• Delivery room• Patients being observed in emergency rooms• Short stay services

Transitions Between Settings

Healthy

Ambulatory (Outpatient)

CareEmergency

Care

Hospital Inpatient Care

Hospital Services in Thailand

Ambulatory (Outpatient)

CareEmergency

Care

Inpatient Care

Surgery (Operating

Rooms)

Why We Need To Hospitalize (Admit) Patients

• Serious illness or injury• Need to monitor patient status closely• Need to observe progression of illness• Need to administer intravenous drugs or fluids• Need extensive/ongoing investigations• Need to observe response to treatment and adjust

plans, or because of potential treatment side effects• Before and after major surgery or procedures• Etc.

Importance of Hospital Services

• Sophisticated capabilities & technologies– Labs– X-rays– Surgeries– Other treatments and technologies

• Integrated services by multiple specialties• Ability to provide level of care needed by each patient

– General wards for different specialties (medicine, surgery, OB-GYN, pediatrics, orthopedics, eye, ENT, etc.)

– Intensive Care Units (ICUs), Cardiac Care Units (CCU)– Public (shared) wards vs. private rooms

• Referral systems of increasing capabilities

Class Discussion #1

• What are some different types of hospitals you can think of?

• What characteristics do you think make these hospitals different?

Types of Hospitals in Thailand

Hospital Category Number of Hospitals

Percentage of All Hospitals

District hospitals (MOPH) 737 56.4%General hospitals (MOPH) 68 5.2%Regional hospitals (MOPH) 26 2.0%Other hospitals under MOPH* 50 3.8%Other public hospitals outside MOPH†

111 8.5%

Private hospitals 315 24.1%Total 1307 100.0%

*Including general and specialty hospitals under other departments within the Ministry of Public Health.†Including university hospitals, military hospitals, autonomous public hospitals, prison hospitals, hospitals of state enterprises, and public hospitals under local governments.MOPH = Ministry of Public HealthSource: Bureau of Policy and Strategy, Ministry of Public Health (November 2010).

Hospital Characteristics

• Geographic location– Province– Urban/rural

• Size– Bed size– Number of employees– Patient volume


• Level of services– Primary care– Secondary care– Tertiary care– Supertertiary care

• Ownership– Public/private status– Parent organization– Being in a multi-hospital system


• Teaching status– Non-teaching hospitals– Teaching hospitals

• Budget• Service capabilities

– Medical technologies available– Medical specialties available

• etc.

Class Discussion #2

• How many of you have had an experience being admitted to a hospital or had a relative who was admitted?

• Can you share some non-confidential parts of the story?– Describe what happened.– What did the providers do to you/your relative in the

hospital?– How was the experience (your feeling of the

experience)?

An Overview of Hospital Services

Services

Information

From Dr. Artit Ungkanont’s slide

Nature of Emergency Care

Source: nj.com

Nature of Ambulatory Care

Ambulatory Processes• Check-in

– Verify Appointment; Update Info; Pull Medical Record

• Move to exam room– Vital Signs; Review Reason for Visit; Document– Examination; Discussion of Findings; Plan; Order; Documents

• Check-out– Schedule appointment– Payment

• After the fact– Complete Documentation/Dictate– Code Visit & File Insurance Claim

Health IT Workforce Curriculum Version 3.0/Spring 2012 Working with Health IT Systems, Under the Hood, Lecture a

A Typical Process for Outpatient Care

Registration (New patients only) OPD Check-in

Verify appointment, insurance eligibility, pull medical records

OPD nurse performs brief history taking,

vital signs measurement

Doctor takes history and physical examination

Doctor writes documentation

Doctor orders investigations (lab, x-

rays, etc.)Doctor reviews results

Doctor writes prescription

OPD Check-outOPD nurse reviews

order, educates patient, makes

appointment (if any)

Patient makes payment

Patient receives medications and go

home

Nature of Inpatient Care

A Typical Process for Inpatient Care

Entry Point Patient registrationAdmission processing

(verify admission paperwork, insurance

eligibility)Patient stays in a ward

Doctor takes history & physical examination in an admission note

Doctor writes order for investigations (lab, x-

rays, etc.) and treatment

Nurse reviews and processes orders

Doctor reviews investigation results

Nurse measures vital signs every 6 hours or

as ordered, writes nurse’s notes

Discharge planningPatient makes

payment, receives home medications &

education, discharged

Hospital makes claims and receives

reimbursements

Inpatient Processes1. Register2. Review Patient Info3. Talk, Observe, Examine4. Document

*H&P, PMH, Signs/Symptoms, etc.5. Take Actions “Orders”

*Meds, Labs, Procedures, Consults, Admit, Next Appt.6. Discharge7. Patient Education (could occur anywhere in the process)8. Health Data Reporting9. Link to Reimbursement


Entry Point for Inpatient Admissions

• From outpatient visits• From emergency room• Referred from another facility• Scheduled inpatient appointment

– Pre-operative (before surgery) admissions– Chemotherapy– Other procedures that require hospitalization

• Operating room– Post-operative (after surgery) care– One-day surgery with unexpected complications requiring admission

Routine Ward Work for Physicians• Morning Ward Rounds

– Check patient’s illness progression, changes from previous rounds, lab/x-ray results, response to treatment

– Plan next steps• Ordering investigations and treatments

– Lab tests– X-rays– Medications and IV fluids– Surgeries & bed-side procedures– Nursing procedures– Diet– Patient activity

• (Optional) Afternoon Ward Rounds• Progress notes & other documentation• Providing treatments during the day as necessary (e.g. CPR)

Routine Ward Work for Nurses• Typically an 8-hour shift• Observe and document patient status, illness progression, and changes• Measure routine vital signs and intake/output• Review and process doctor’s orders• If patient condition is serious or urgent, inform physicians• Perform nursing interventions as ordered• Coordinate with other departments and staff• Assist physicians in bed-side procedures• Documentation

– Nurse’s notes– Medication administration records (MARs)– Vital sign– Kardex (for within-shift communications and between-shift hand-over)– Other administrative documents

Discharge Status

• Discharged home with approval• Left against medical advice• Escape• Referred to another facility• Expired (Dead)

What Is Different?• Access to systems & data• Challenges of geography• Patient Load• Episode of Care• Facilities and technologies available• Level of monitoring and control of environment• Coordination, Communication, Consultation

Health IT Workforce Curriculum Version 3.0/Spring 2012 Modified from “Working with Health IT Systems, Under the Hood, Lecture a”

Inpatient vs. Ambulatory Processes: Comparing and Contrasting

How do they differ?– Inpatient 4 phases

• Initial evaluation• Ongoing Management • Pre-discharge• Discharge

– Ambulatory• Episodic• Coordination across providers and locations• Monitoring/treatment chronic & acute


Managing Hospital Operations

• Typical Organizational Structure– Hospital Director as top executive– Various clinical departments depending on medical

specialties and services available– Nursing Department

• Important Administrative Departments– Director’s Office– Quality improvement, Risk management– IT– Finance, Human Resource (HR), Procurement– Academic/Education/Research

Supporting Care Processes with HIT

• Facilitate filtering, organizing, & access• Thoroughness and currency imperative• Reviewing & Documenting• Planning• “Doing” – ordering• Educating


Supporting Care Processes with HIT

• Communicating– High risk, high stress– Teams – working independently but

with constant information exchange– Moving patients, moving providers, rapidly changing

situations


IT Management in Hospitals

• Front Office– Hospital Information Systems (or Clinical Information Systems)

• Back Office– Management Information Systems– Including Enterprise Resource Planning (ERP) systems– Research and Education– Office Automation Tools

• Data Warehouse, Data Analysis & Reporting• IT Infrastructure

– Systems & Network Administration, including Security– Web Sites

Workflow

Hospital Information System

Master Patient

Index (MPI)

ADT

Scheduling

Order

Pharmacy IS

Operation Theatre

Billing

Clinical Notes

LIS

RIS

PACS

CCIS

Medical Records

Portals

Modified from Dr. Artit Ungkanont’s slide

HIT Systems (Inpatient)Clinical Decision Support:“Any system designed to improve clinical decision making related to diagnostic or therapeutic processes of care.”

From Dr. Artit Ungkanont’s slide

Care Processes: HIT Support• Registration

– Admission, Discharge Transfer Systems (ADT)– Bed Management Systems (BMS)– Unique Identifier – i.e. Hospital Number (HN),

sometimes called Medical Record Number (MRN)

Health IT Workforce Curriculum Version 3.0/Spring 2012 Working with Health IT Systems, Under the Hood, Lecture b

Care Processes: HIT Support• Reviewing Patient Information

– Retrieve patient record • Verifying demographics, etc.• Past medical history, etc.

• Talking, Observing, Examining


Care Processes: HIT SupportDocumentation

– Copious• Pick lists, Voice Recognition, Structured Notes, Integrated

Records, Patient-Centered, Kiosks, PHRs …

– Knowledge Resources & Decision Support


Care Processes: HIT SupportTaking Action Performing/Ordering/Reviewing

– CPOE – Computerized Prescriber Order Entry • E-prescribing, Consults, Treatments, Diets, Labs, Tests…

– Guideline-based Care http://www.guideline.gov/

Health IT Workforce Curriculum Version 3.0/Spring 2012 Modified from Working with Health IT Systems, Under the Hood, Lecture b

Computerized Physician Order Entry (CPOE)

Care Processes: HIT Support• Pre-Discharge/Discharge

– Ties into ADT, bed management, discharge planning …

• Education


Care Processes: HIT Support• Reporting & Reimbursement

– External (Disease Control & Prevention, Immunization Registries, Payers for reimbursement, etc.) & Internal (Practice Improvement, Trending, etc.)

– $$$


Summary• Hospitals are an important setting in health care• Nature and work processes in the inpatient,

outpatient, and emergency settings are quite different

• These settings have some common needs for health IT, but each also has unique needs

• Hospitals are just one part of the whole healthcare system

Health IT Workforce Curriculum Version 3.0/Spring 2012

Working with Health IT Systems Under the Hood

Lecture b

Healthcare System: The Big Picture

Hospital A Hospital B

Clinic C

Government

Lab Patient at Home

QUESTIONS?

Hospital Services & Management

Health & Medicine

Transcript of Hospital Services & Management