Advancing health system integration through supply chain improvement

Collaboration is a key element to success in the provision of sustainable and integrated healthcare services. Among the many initiatives undertaken to improve service quality and reduce costs, collaboration among hospitals in Ontario has been difficult to achieve; however, voluntary collaboration is vital to achieving transformation of the magnitude envisioned by system leaders.

A centralized system to access acute healthcare services: the pros and cons

Having a centralized access service results in a daily interconnetedness between hospital sites, which can create many benefits but also much controversy. Knowing the pros and cons of a centralized service and understanding the role and work environment of the access coordinator will assist you in deciding if this service would be of benefit to your health region. In this descriptive analysis of a centralized access model, a regional perspective is presented; however many of the strategies can be adopted to a single hospital service resulting in improved flow in clinical areas.

Shared care with task delegation to nurses for type 2 diabetes: prospective observational study

BACKGROUND

To study the effects of two different structured shared care interventions, tailored to local needs and resources, in an unselected patient population with type 2 diabetes mellitus.

METHODS

A three-year prospective observational study of two interventions and standard care. The interventions involved extensive (A) or limited (B) task delegation from general practitioners to hospital-liaised nurses specialised in diabetes and included a diabetes register, structured recall, facilitated generalist-specialist communication, audit and feedback, patient-specific reminders, and emphasised patient education. The target population consisted of 2660 patients with type 2 diabetes treated in the primary care setting. Patients who were terminally ill or who had been diagnosed with dementia were excluded from the study.

RESULTS

The participation rates were high (90%) for patients, and none of the 64 GPs discontinued their participation in the study. Longitudinal analyses showed significant improvements in quality indicators for both intervention groups (process parameters and achieved target values on the individual patient level); in standard care, performance remained stable or deteriorated. Both patients and caregivers appeared satisfied with the project.

CONCLUSION

This study shows that structured shared care with task delegation to nurses, targeted at a large unselected general practice population, is feasible and can positively affect the quality of care for patients with type 2 diabetes.

Integration of an academic medical center and a community hospital: the Brigham and Women's/Faulkner hospital experience

Brigham and Women's Hospital (BWH), a major academic tertiary medical center, and Faulkner Hospital (Faulkner), a nearby community teaching hospital, both in the Boston, Massachusetts area, have established a close affiliation relationship under a common corporate parent that achieves a variety of synergistic benefits. Formed under the pressures of limited capacity at BWH and excess capacity at Faulkner, and the need for lower-cost clinical space in an era of provider risk-sharing, BWH and Faulkner entered into a comprehensive affiliation agreement. Over the past seven years, the relationship has enhanced overall volume, broadened training programs, lowered the cost of resources for secondary care, and improved financial performance for both institutions. The lessons of this relationship, both in terms of success factors and ongoing challenges for the hospitals, medical staffs, and a large multispecialty referring physician group, are reviewed. The key factors for success of the relationship have been integration of training programs and some clinical services, provision of complementary clinical capabilities, geographic proximity, clear role definition of each institution, commitment and flexibility of leadership and medical staff, active and responsive communication, and the support of a large referring physician group that embraced the affiliation concept. Principal challenges have been maintaining the community hospital's cost structure, addressing cultural differences, avoiding competition among professional staff, anticipating the pace of patient migration, choosing a name for the new affiliation, and adapting to a changing payer environment.

A novel program to increase the number of women patients seen by residents in a VA hospital

A recent requirement from the Accreditation Council for Graduate Medical Education that internal medicine residents must provide care for a minimum of 25% of female patients in their longitudinal clinics has posed difficulties for Internal Medicine programs that utilize Department of Veterans Affairs (VA) hospitals for outpatient training. The authors report an innovative program developed at a Connecticut VA hospital for internal medicine residents at the Yale University School of Medicine. Residents participate in the clinic at the VA Women's Health Center every fourth week instead of attending their usual VA primary care clinic. To increase the numbers of patients being seen by residents, the "Sharing Program" was initiated in 2001 so that wives of veterans could be seen in the VA women's clinic. Sharing Program patients are billed for their care by the Yale University Medical Group and the VA is reimbursed by the University Medical Group for the cost of providing care to these patients. As a result of the Sharing Program, the mean proportion of female patients assigned to residents has reached 25%. Surveys showed high levels of patient and resident satisfaction, and that residents perceived an improvement in their education in the outpatient care of women.

Sterilisation services. Knife point

Sterile services departments are in such a poor state that new centres are needed. A super-centre, shared between local trusts, is to be tried in Bradford and Leeds. Stocks and movement of instruments will need close monitoring under a centralised system.

A model for consolidation of clinical microbiology laboratory services within a multihospital health-care system

To determine the cost-effectiveness of consolidating clinical microbiology services in a three-hospital health-care network while maintaining high-quality laboratory services, a retrospective review of the total costs of maintaining separate clinical microbiology laboratories within our health-care system was compared to the cost of providing these services after consolidation. Turnaround times before and after consolidation were compared to assess efficiency of the consolidated services. Input of clinicians was also solicited to ensure that quality of services and customer satisfaction remained high. The results of the consolidation project show that the net fiscal saving because of consolidation of clinical microbiology services within our health-care system will be approximately 100,000 dollars per fiscal year. This value includes increased courier charges as well as personnel savings. Although fiscal savings are an integral part of any laboratory consolidation plan, the financial considerations must be balanced by quality of service. The response to consolidation from clinicians was decidedly mixed before implementation of the plan because of fear of increased turnaround times and limited access to laboratory information. The consolidation process, however, was smooth with few physician complaints. The consolidation of our clinical microbiology services illustrates that significant financial savings can be achieved without compromise of efficiency or quality of service.

Paperless medical records: reinventing the patient experience

At North Shore Magnetic Imaging Center, the patient paper medical record system was becoming very cumbersome, and it served as a source of frustration for everyone involved: patients, technologists, radiologists, and staff members. The center's mapping of a typical patient experience indicated that, from the initial phone call scheduling an exam to a completed visit (claim processed and payment received), a record could be handled by as many as 20 sets of hands! In June 2002, the center's growth and a concern that patients were losing a one-on-one experience with the medical staff led to an evaluation of workflow processes existing at that time. The evaluation began with a survey of staff members, center management, radiologists, and referring physicians. Their responses indicated 3 common themes: stress, overload, and frustration over systems in place. Comments from the survey were grouped into 3 areas: Continue to Do, Stop Doing, and Start Doing. The Start Doing responses provided solid objectives. The center set out to establish a breakthrough project that included all stakeholders--patients, staff, management, and radiologists. The Reinvention Project had 2 primary goals: move to a paperless environment and increase the level of patient care. The project was divided into internal and external teams. The internal team, called the Reinvention Team, was responsible for the actual hands-on aspects of the process. There were numerous external teams; each had defined roles and specific outcomes for achievement. The external teams' responsibilities included implementing an Internet protocol telephone system; researching voice recognition; restructuring job descriptions, training manuals, and performance evaluations; and conducting a patient-centered focus group.

Approaches towards a regional, shared electronic patient record for health care facilities of different health care organizations--IT-strategy and first results

Today, information processing in healthcare facilities is usually primarily directed towards the information needs of the respective institution. This stands in apparent contradiction to the fact that patients may not be solely treated in one general practice or hospital. More information processing towards patient-centered, shared care would better support high quality as well as efficient health care. We developed a stepwise approach transforming trans-institutional information system architectures (TISAs) from an inefficient state caused by redundancy and media cracks towards a state which better supports patient centered, shared care. In a total of three steps we want to establish electronic communication between existing information systems of different healthcare facilities for transmission of discharge summaries and diagnostic results. In further stages we plan to expand this communication solution to a regional comprehensive and consistent electronic patient record for multiple hospitals and general practices in Tyrol, Austria. In addition, two related approaches towards supporting shared care have been compared with our approach. The aim of this paper is to report on our approach and first experiences.

Choosing networks for picture archiving and communication systems and teleradiology

Qualitative interviews were performed with 26 resource persons with experience of picture archiving and communication systems and teleradiology. The results reported here concern the different types of networks there was interest in establishing. Eight types of networks were considered to be of interest. The two main reasons for wanting the networks were related to clinical communication and improved exploitation of resources. Use of such networks means cooperation across organizational boundaries. Networks can play an organizational role and this raises questions concerning the future organization of radiology services.

[Mammography referral center combined with breast cancer center]

Carcinoma of the breast is, with 26.7% of all malignancies, the most commonly diagnosed tumour in women, every eighth female Austrian suffers from this disease. Similar figures are reported from other European countries. Following recommendations of scientific societies like the European School of Mastology (ESOMA) or the British Breast Group, breast diseases should be treated by interdisciplinary teams in dedicated breast centers. Many such institutions exist in Austria and international, but only few of them are organized optimally and fulfill the requirements of an internationally accredited breast cancer centre.

Using the ISMP Medication Safety Self-Assessment to improve medication use processes

BACKGROUND

The 194-item Institute for Safe Medication Practices (ISMP) Medication Safety Self-Assessment for hospitals is being used by a 21-hospital collaborative as a framework for understanding, evaluating, and systematically implementing medication use system safety improvements.

METHODS

The results of the self-assessment were used to prioritize and organize the review of medication use processes, in which each self-assessment-defined "representative characteristic" is reviewed in detail, and "best implementation practices" for the characteristic are established. The collaborative concurrently identifies educational needs and develops tools to assist organizations in implementing improvements.

RESULTS

By December 2002 participating organizations had implemented a wide variety of medication safety improvements. Collaborative member scores for the self-assessment increased approximately 20% during the initial assessment when the self-assessment was repeated by members in the second quarter of 2002.

SUMMARY

Participant progress in improving medication safety practices is supportive of collaborative methods and the value of completing the ISMP self-assessment, expanding on the knowledge gained, developing effective implementation tools, and systematically applying lessons learned.

Advantages of a multi-facility information technology consortium

The formation of an information technology consortium has proven to be a way for several rural hospitals in Northern Minnesota to purchase and successfully install the right technology solutions for their facilities. The concept described is very similar to that used by the Independent Grocer Alliance (IGA), which allows local independent grocers to buy products at prices comparable to these obtained by larger chain stores.

The cost effectiveness of a nurse-led shared-care prostate assessment clinic

OBJECTIVE

Nurse-led prostate clinics (NPCs) have proved to be a highly effective method of assessing patients with lower urinary tract symptoms (LUTS) and most urology units now run such clinics. However, it was not known whether they are cost-effective and this analysis ansWers that question.

PATIENTS AND METHODS

During one year, a trained urology nurse assessed 1,080 patients in our NPC following GP referral using a standard pro forma. Costs included those incurred for the salary of a grade D nurse at 30 min per patient, all investigations, indirect charges and overheads. This was compared to the cost of seeing all patients in clinic directly, either by a consultant, staff grade urologist or registrar. Of these 1,080 patients, 350 were sent back to their GPs after NPC assessment.

RESULTS

The NPC cost of 44.25 pounds per patient compared favourably with an average medical out-patient clinic cost of 50.46 pounds per patient, yielding an actual annual saving of 6,706.80 pounds. Since a third of the patients assessed in the NPC were sent directly back to primary care, saving the cost of a medical follow-up appointment, the true savings in secondary care were 17,661.00 pounds (50.46 x 350pounds), giving a total annual saving of 24,367.80 pounds.

CONCLUSIONS

A nurse-led shared-care prostate clinic is a cost effective, thorough and speedy method of assessing men presenting with suspected bladder outflow obstruction. The approach used has a wider generic, cost-benefit potential for the NHS.

A post-1990s assessment of strategic hospital alliances and their marketplace orientations: time to refocus

In past years, many SHAs formed in local urban markets to better compete for managed care contracts. In response to 1990s forces, these SHAs appear to have adapted product, production, and selling orientations to their markets, aimed at large institutional purchasers of health care. However, health care markets have evolved differently than anticipated. SHAs and their hospitals should now adopt the marketing orientation and focus more on patients and enrollees.