Operations in the Clinical Settings

Operations in the Clinical Settings

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

January 8, 2013

TMHG 541: Fundamentals of Health Care and Medical Terminology

Outline• Overview of healthcare delivery• Ambulatory & emergency care• Hospital and inpatient care• Nature of hospital services• Contrast with ambulatory & emergency settings• Management of hospital operations• Needs for health IT in hospitals• Conclusion

OVERVIEW OF HEALTHCARE DELIVERY

Functions of Healthcare Systems

4

The Healthcare System

Hospital A Hospital B

Clinic C

Government

Lab Patient at Home

Stakeholders in Health Care

Public/Population

Providers

Policy-Makers

Patients

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

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

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

Providers of Healthcare Delivery

• 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. In Thailand, payers include:– 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!!


• 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

AMBULATORY & EMERGENCY CARE

Outpatient/Ambulatory Care

• Outpatient = not hospitalized• Patient visits an "outpatient facility" for care• Outpatient facilities

– Physician’s offices• Primary care offices• Specialty care offices• Single specialty or multispecialty offices

– Outpatient clinics within hospitals in some countries

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Adapted from materials developed by Oregon Health & Science University, funded by the Office of the National Coordinator for Health Information Technology, U.S. Department of Health and Human

Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 3a).

Other Outpatient Facilities– Dental offices

• General dentists or specialists

– Medical and diagnostic laboratories– Urgent Care Centers– Mental Health Clinics– Alcohol and Substance Abuse Treatment Center– Outpatient Surgical Centers– Physical and Occupational Therapy Centers– Home Health– Hospice Care

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What Is Primary Care?

• The care provided by certain clinicians– Non-specialist physicians (general practitioners)– Primary care medical specialties are

• family medicine• general internal medicine• general pediatrics• obstetrics and gynecology

• Do only physicians provide primary care?– nurse practitioners, physician assistants

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• A level of care or setting– Other levels:

• Secondary care• Tertiary care

• Primary care is the entry point to a system• Ambulatory versus inpatient care

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• A strategy for organizing the healthcare system as a whole– Example: community-oriented primary care – Greater emphasis on community-based healthcare– Lesser emphasis on hospital-based, acute-care

medicine

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The Patient-Clinician Relationship

Image: Primary Care: America's Health in a New Era-1996.

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• The narrow view– If primary = “first” in time or order– Then primary care = “ground floor” of healthcare

delivery• The broad view:

– If primary = “chief” or “main”– Then primary care = “central” to healthcare

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What Is Primary Care?• A set of attributes

– The 1978 IOM definition: • Care that is

– Accessible– Comprehensive– Coordinated– Continuous

– Perspectives:• The patient and family• The community• The ecosystem

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• The definition of primary care adopted by the IOM Committee on the Future of Primary Care:– Primary care is the provision of integrated, accessible

healthcare services by clinicians who are accountablefor addressing a large majority of personal healthcare needs, developing a sustained partnership with patients, and practicing in the context of family and community.

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• Integrated - provision of services that are:– Comprehensive– Coordinated– Continuous– A seamless process of care combining events and

information that occur in different settings

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• Accessible – how easy is it for patients to initiate an interaction for any health problem with a clinician?– What are the efforts to eliminate barriers to patient

care?• Healthcare services – array of services that are

performed by healthcare professionals for the purpose of promoting, maintaining or restoring health

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• Clinician means an individual who uses a recognized scientific knowledge base and has the authority to direct the delivery of personal health services to patients.

• Patient means an individual who interacts with a clinician either because of illness or for health promotion and disease prevention.

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• Sustained partnership – the relationship established between the patient and clinician with the mutual expectation of continuation over time.

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• Accountable care – primary care clinicians and the systems in which they operate in are responsible to their patients and communities for– quality of care– patient satisfaction– efficient use of resources– ethical behavior

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• Majority of personal healthcare needs –primary care clinicians are trained to diagnose and manage a large majority of problems that patients present with– When appropriate, primary care clinicians may

involve specialists

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Where Is Primary Care Delivered?

• Primary care clinic:– Point of delivery– A medical facility

• Usually, the conditions seen at a primary care clinic are not serious or life threatening

• “Gateway” to healthcare services

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Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 3b).

Primary Care Medical Specialties

• Family Practice• General Internal Medicine• Pediatrics• Obstetrics and Gynecology (OB/GYN)

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Family Practice

• Family Practice (also known as Family medicine):– Provides healthcare for the individual and family– Integrates biological, clinical and behavioral sciences– The scope of family medicine is broad

• encompasses all ages, both sexes, each organ system and every disease entity

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General Internal Medicine

• Doctors of internal medicine also known as “internists”

• Focus on adult medicine• Special study and training focusing on the

prevention and treatment of adult diseases.

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Pediatrics

• Is the branch of medicine that deals with the medical care of infants, children, and adolescents

• Focuses on diagnosing, treating and preventing diseases that affect children

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Obstetrics and Gynecology

• Obstetrics – care of women during pregnancy and immediately after childbirth

• Gynecology – care of the female reproductive system

• Women’s health and GYN preventive care are an important facet of primary care

• Often the same clinician provides both OB and GYN services

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Specialty Care

• A specialty is a branch of medicine• After completing medical school, physicians train

in a specific field (their specialty)• Some physicians undergo additional training

(fellowships) after initial training in a more general field

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Examples of Specialties

• Dermatology• Pathology• Radiology• Nuclear Medicine• Psychiatry• Emergency Medicine• Preventive Medicine

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Specialty clinics

• Medical specialties• Examples:

– Cardiology– Immunology– Gastroenterology

• Surgical specialties• Examples:

– Orthopedic surgery– Neurosurgery– Plastic surgery

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Delivery of Specialty Care

• Many surgical specialists see patients in outpatient clinics

• They perform surgeries in hospitals• They may perform surgeries in outpatient

surgical centers

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Outpatient Surgical Centers

• Many surgeries or procedures are done in the hospital, either on an inpatient or outpatient basis

• Some surgeries or procedures are done in outpatient (or ambulatory) surgical centers– Surgery or procedures are performed in a non-hospital

location– Patients typically go home after a brief period of

recovery (a few hours), following the procedure/surgery

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Primary Care In Crisis?

• Increasing number of older patients with complex medical issues

• Imperfect coverage of preventive care services• Emphasis on documentation & administrative

reporting• U.S.: Complex billing and compensation system

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Primary Care In Crisis?

• Decreasing number of physicians practicing primary care

• Supply-demand imbalance• Greater dependence on after-hours care

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Why is Primary Care In Crisis?

• Fewer U.S. graduates enter family medicine• Only a minority of first year internal medicine

residents pursue careers in primary care• Specialists are better compensated than primary

care physicians

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Why Don’t Physicians Want To Go Into Primary Care?

• A 2007 survey of graduating U.S. medical students: only 2% planned a career in general internal medicine

• Debt not as much of a negative factor as the challenge of treating elderly and chronically ill patients with complex medical issues

• Practice environment and lifestyle also played a role

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Solving The Primary Care Crisis: U.S. Efforts• Health reform and federal stimulus funds• Shift in training from emphasis on specialty care• Grants for training and educational innovation• International Medical Graduates• Recruitment• Loan forgiveness and other financial

inducements

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Outpatient care: Retail Clinics

• Facilities usually located in stores or pharmacies, may also be free-standing

• Staffed by nurse practitioners – nurses with additional training

• Intended to treat common and minor illnesses

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Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 3c).

Outpatient Care: Urgent Care Centers

• Over 8500 acute care centers in the U.S.• Growing trend since the 1970s• Urgent care centers are usually walk-in• May have extended hours• Usually provide care that may be beyond the

scope of care of typical primary care practice

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Outpatient Care: Urgent Care Centers (Continued)

• Typically have laboratory and/or X-ray facilities on-site

• Some may have more advanced diagnostic equipment

• Not intended to treat life-threatening emergencies

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Outpatient Care: Emergency Department (ED) or Emergency Room (ER)

• In 1996 there were 90.3 million U.S. ER visits• By 2006 the number had risen to 119.2 million• The age group with the highest annual per

capita ER visit rate was infants under 12 months of age

• 12.8% (15.3 million ER visits) resulted in admission to the hospital in 2006

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Outpatient Care: ED or ER continued

• Emergency rooms (ERs) are intended to treat life-threatening emergencies

• However, a substantial number of ER visits are for non-emergencies

• Approximately 11 percent of all ambulatory medical care visits in the U.S. occur in the ER

• The number of non-emergency ER visits may be very high

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Effects of Overcrowding In The ER

• Delays in the treatment of serious medical conditions

• Increased waiting times• Reduced promptness and quality of pain

management• Hallway boarding of admitted patients• Ambulance diversions• Decreased physician productivity

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Why so many ER visits?

• In upstate New York, 45% of potentially unnecessary ER cases were seen between 9 am and 5 pm

• Could this be a consequence of the “primary care crisis”?

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Causes of Non-emergency ER visits

• Patients may not have primary care providers• Many primary care clinicians are over-

extended• Lack of insurance is often a barrier to care• Patients with higher rates of chronic medical

conditions may seek a greater proportion of their care from the ER

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Another Reason for ER Overcrowding

• Crowded ERs could be a result of high inpatient occupancy rates (no available beds) and inefficient inpatient stays (poorly planned discharges, longer length of stay, etc.)

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Reducing Inappropriate ER Visits & ER Overcrowding• Patient education & information is key• Establish medical homes for better care

coordination• More effective triage system• Improve the availability of after hours care• Increase enrollment in safety net programs• Better prevention• More efficient inpatient stay management

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Outpatient Laboratories

• Laboratory where tests are done on clinical specimens

• May be associated with a hospital or be freestanding

• The testing may be done in a location remote to the location where specimen was obtained

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Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 3d).

What Can Laboratories Do? Pathology

• Anatomical Pathology• Histopathology – studies whole tissues• Cytopathology – at the cellular level• Electron microscopic pathology

• Surgical Pathology• Chemical Pathology (clinical chemistry)

• General chemistry• Endocrinology• Immunology• Toxicology

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Pathology (continued)

• Hematopathology– Diseases of blood cells

• Traditional microscopy• Immunohistochemistry• Flow cytometry• Molecular diagnostic tests

• Blood banking - Transfusion medicine• Cytogenetics

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Pathology (continued)

• Clinical microbiology – study of microorganisms– The lab may use culture methods to grow and identify

organisms• Forensic pathology

– Specialized laboratory for medical and legal issues• Molecular pathology

– Development of molecular and genetic approaches to the diagnosis and classification of human tumors

– Design and validation of predictive biomarkers

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Radiology services

• Radiology – branch of medicine that uses imaging technology to diagnose or treat diseases

• Radiologists – physicians who specialize in radiology

• Outpatient radiology services may be housed within a hospital or may be freestanding

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Radiology services• Diagnostic radiology

– X rays• First X-ray taken by Wilhelm Röntgen in 1895 (his wife’s

hand)

Image: (Röntgen, 1895)

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Radiology services

• Diagnostic radiology– Computerized Tomography (CT) scans– Magnetic Resonance Imaging (MRI) scans– Positron Emission Tomography (PET) scans– Ultrasound – Mammography – Bone density tests– Nuclear medicine tests

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Radiology services

• Interventional radiology – invasive tests– Angiography

• Teleradiology allows radiologists to review images remotely

• Technology allows images to be archived and retrieved at multiple sites – Picture Archiving and Communication System or PACS

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Ancillary Services

• Home healthcare (home care)• Care provided at the patient’s home• Physician house calls• Nurse visits• Home health aides• Help with activities of daily living (ADLs)

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Ancillary Services

• Hospice care• For patients whose life expectancy is not

expected to exceed 6 months (terminally ill patients)

• Palliative care outside the hospital• At hospice institutions• At home• Multidisciplinary team for care

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Ancillary Services

• Physical therapy– Maintains function after injury or illness

• Occupational therapy– Helps patients maintain occupation

• Speech therapy– Helps patients recover from diseases that affect

speech• Care provided by ancillary staff

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HOSPITAL AND 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• Periodic supervision of patients• 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

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.

Community Hospitals

• Short-term, general public hospitals– Provide general or specialty care– Provide cost-effective and accessible

care– In Thailand, have 10-100 beds, located

mostly in rural areas, provides general primary care

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Teaching/Research Hospitals

• Large institutions affiliated with medical schools– Employ state-of-the-art medications, surgical

procedures, equipment, technology– Treat complex medical problems, rare diseases– Teach physicians and other healthcare providers– Support and perform medical research– Provide critical care for the community

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Critical Access Hospitals (U.S.)

• Certified for reimbursement by Medicare• Typically are licensed acute-care hospitals in

rural locations• Sometimes health clinics are eligible• Reimbursement may save the hospital from

closing

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Class Discussion

• 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

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

Exact process varies in different locations/organizations

Nature of Inpatient Care

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

Exact process varies in different locations/organizations

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

Adapted from 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 (Health

IT Workforce Curriculum v.3.0/Spring 2012, Component 7/Unit 2a).

Inpatient vs. Ambulatory Processes: Comparing and ContrastingHow do they differ?

– Inpatient 4 phases• Initial evaluation• Ongoing Management • Pre-discharge• Discharge

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

Adapted from 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 (Health

IT Workforce Curriculum v.3.0/Spring 2012, Component 7/Unit 2a).

Hospital Clinical Structure: Overview

• Hospitals contain specialized areas– General inpatient care is provided in wards– Immediate care is provided in the ER– Surgery is performed in the operating room (OR)– Critical care is given in intensive care units (ICUs)

and critical care units (CCUs)– In some settings, also have outpatient departments

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Hospital Setup: ER

• ER is open 24 hours, 7 days a week• Treats various types of injuries

– Ranging from ankle sprain to drug overdose– Severity is assessed by a process called triage

• Patients are treated completely or sent to other hospital areas

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Hospital Setup: OR

• Surgery is done in the OR– Sterile environment is required– Surgical team includes variety of healthcare

workers (surgeons, nurses, anesthesiologists)– OR contains surgical instruments, monitoring

equipments, emergency equipments

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Hospital Setup: ICU/CCU

• ICUs treat patients with severe disease or injury (e.g., pneumonia, traumatic injury)

• CCUs are for cardiac (heart) disease• Patients come from ER, OR, ward, or

another hospital• Various interventions are performed• Sophisticated equipment is used

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Personnel Who Provide Serious Acute Care• Emergency medicine

– Goals: save lives of patients, provide short-term care– Patients receive care at the accident scene by

emergency medical technicians (EMTs) or paramedics, who are more highly trained than EMTs

– ER care is a physician specialty• Critical care

– Goals: treat life-threatening conditions, provide longer-term care

– ICU and CCU care are also physician specialties

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Other Hospital Personnel• Surgeons perform operations, sometimes special types (for

example, orthopedic surgery, plastic surgery)• Anesthesiologists monitor patients in the OR and treat pain

(for example, in the ICU or during childbirth)• Other physician specialties exist (for example, internal

medicine, cardiology, obstetrics/gynecology, psychiatry) • Medical subspecialties also exist (for example, pediatric

cardiology)• Registered nurses (RNs), licensed practical nurses (LPNs),

and physician assistants (PAs) may also specialize• Pharmacists evaluate and dispense medications

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Ancillary Personnel• Nursing assistants work under the direction of RNs and

LPNs• Technicians help with treatment or diagnosis (for

example, phlebotomists, x-ray and ultrasound technicians, laboratory personnel)

• Therapists facilitate rehabilitation (for example, physical, occupational, respiratory, or speech)

• Other workers educate and counsel (for example, dietitians, nutritionists, diabetes educators, social workers)

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Hospital Corporate Structure• Governing board (board of directors) provides oversight• Chief executive officer or hospital director is responsible

for daily operations• Administration also includes chief officers, department

heads, patient care managers• Medical staff and ancillary personnel provide healthcare

and technical services• Nonmedical services are also critical (for example,

cooks, laundry workers)• Business office does paperwork and provide supporting

services (for example, billing, scheduling)

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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

Hospital Financing• Ownership may be public or private

– Public hospitals are funded by the government, may have limited resources

– Private hospitals are run by private entities, may have greater resources (for example, finances, equipment)

– Funding could be in the form of directly allocated budgets and/or reimbursements of services provided

• Either type of hospital may be for-profit or nonprofit– In Thailand, public hospitals are non-profit

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Hospital Systems

• A hospital system is 2 or more hospitals owned by a corporation, with a single board of directors

• A network is a group of hospitals, physicians, and other entities that collaborate to provide care in a community

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Summary• Health care is delivered in several settings, each having

its own nature and context• Fragmented care by specialists and increasingly

complex chronic disease patients highlights the importance of primary care in the ambulatory setting

• ER overcrowding is a critical issue in emergency setting• Hospital inpatient care is an important component of

health care.• There are various levels and types of hospitals to

address diverse and complex patient needs• Healthcare delivery by providers is just one part of the

overall healthcare system

Health & Medicine

Operations in the Clinical Settings