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00 cover vol46.4.ai 4/1/11 12:55:14 2010 Volume 46 Number 4 World Hospitals and Health ServicesThe Official Journal of the International Hospital Federation Striking a balance between national interests and patients' needs: Cross-border projects meeting European challenges Crisis management, capabilities and preparedness: the case of public hospitals in Iran Patient-centred care: more than the sum of its parts – Planetree's patient-centred hospital designation programme At the Crossroads: NRTRC white paper examines trends driving the convergence of Telehealth, Please tick your box and pass this on: Institutional transfer from the European design practices to Ukraine and Moldova: the ■ Medical director case of hospital design ■ Nursing director Quality and culture of health ■ Head of radiology Hospital marketing: characterization of marketing ■ Head of physiotherapy actions in private hospitals in the city of São ■ Senior pharmacist Paulo – Brazil ■ Head of IS/IT Clinical careImproving health workers' access to HIV and TB ■ Laboratory director prevention, treatment, care and support services ■ Head of purchasing ■ Facility manager 00-01 Contents 46_8:27 4/1/11 13:05 Page 1 00-01 Contents 46_8:27 7/1/11 10:37 Page 1 Contents volume 46 number 4 03 Editorial Eric de Roodenbeke
Editorial StaffExecutive Editor: Eric de Roodenbeke, PhD 04 Striking a balance between national interests and patients' needs: Cross-border projects
Ioana Rusu, MA.
meeting European challenges Renate Burger and Thomas Kostera Editorial BoardDr René Peters Dutch Hospital Association 07 Crisis management, capabilities and preparedness: the case of public hospitals in Iran
Norberto LarrocaCamara Argentina de Empresas de Salud Dr Harry McConnellGriffith University School of Medicine (Australia) 13 Patient-centred care: more than the sum of its parts – Planetree's patient-centred hospital
Dr Persephone DoupiSTAKES designation programme. Susan B Frampton and Sara Guastello 17 At the crossroads: NRTRC white paper examines trends driving the convergence of
Immeuble JB SAY,13 Chemin du Levant, Telehealth, EHRs and HIE Christina Beach Thielst 01210 Ferney Voltaire, FranceEmail: info@ihf-fih.org 24 Institutional transfer from the European design practices to Ukraine and Moldova: the
case of hospital design Rodica Plugaru Subscription OfficeInternational Hospital Federation 27 Quality and culture of health
c/o Fairfax House, 15 Fulwood Place, London WC1V 6AY, UK Sara Alicia Ponce de León Muñoz Telephone: +44 (0) 20 7969 5500;Facsimile: +44 (0) 20 7969 5600 30 Hospital marketing: characterization of marketing actions in private hospitals in the city of
São Paulo – Brazil Eduardo Blay Leiderman, Jorge Luis Padovan and Paola Zucchi Published by Pro-Brook Publishing Limited for the International Hospital Federation 34 Improving health workers' access to HIV and TB prevention, treatment, care and support
13 Church Street, services Sophia Kisting, Susan Wilburn, Myroslava Protsiv and Lee-Nah Hsu Woodbridge,Suffolk IP12 1DS, UKTelephone: +44 (0) 1394 446006 Fax: +44 5601 525315 37 Language abstracts
For advertising enquiries contact 40 IHF corporate partners
Pro-Brook Publishing Limited on +44 (0) 1394 446006 43 Governing Council list
World Hospitals and Health Services is publishedquarterly. All subscribers automatically receive a copy 44 Dates for your diary
of the IHF reference books. The annual subscription tonon-members for 2010 costs £175 or US$250.
World Hospitals and Health Services is listed inHospital Literature Index, the single mostcomprehensive index to English language articles onhealthcare policy, planning and administration. The index is produced by the American HospitalAssociation in co-operation with the National Library ofMedicine. Articles published in World Hospitals andHealth Services are selectively indexed in Health CareLiterature Information Network.
The International Hospital Federation (IHF) is anindependent non-political body whose aims are toimprove patient safety and promote health inunderserved communities. The opinions expressed inthis journal are not necessarily those of theInternational Hospital Federation or Pro-BrookPublishing Limited.
World Hospitals and Health Services Vol. 46 No. 4 01
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Cancellation Dates:Before 10th June, 2011 90% reimbursedBetween 10th June and 10th August 2011 80% will be reimbursedAfter 10th August 2011 no reimbursement INDEX Conferences and Exhibitions Org. Est P.O. Box 13636, Dubai - UAE Ibn Sina Bldg. Block B, Office 203 Dubai Health Care CityTel + 971 4 362 4717, Ext 127 Fax + 971 4 362 4718 E-mail: ihfdubai@index.ae Website: www.ihfdubai.ae 03 Editorial:28 4/1/11 13:45 Page 3 ERIC DE ROODENBEKE
CHIEF EXECUTIVE OFFICER, INTERNATIONAL HOSPITAL FEDERATION As we are coming to the end of 2010 it is clear that the evolution of their hospitals it is important for them to learn from economic crisis will not cease very soon as announced others. This is happening in countries which used to be fully under earlier by the governments. It may even get worst if there is Soviet influence moving now from a "one size fits all approach" to an increased pressure on all the indebts countries triggered by a customized response. The article describing the situation in international speculation on currency.
Ukraine and Moldova gives us a very good description of Anyhow it is clear that reducing the deficits is a priority for most transformation. Without underestimating the specific situation of a of these governments and this will be translated by budget cuts country much can be achieved by taking advantage of best affecting the health care sector in many countries. But this overall practices from abroad.
economical situation is also affecting the behavior of the insurance When it comes to health workers safety there are no borders for and the corporate sector. Every one is looking on how to save good options. All countries have to face HIV and TB which can put money. This obliges to revise the order of priorities, which is a at risk health workers if appropriate measures are not in place. The fact that this article is written by representatives from the Some may consider that spending on international organization International Labor Organization (ILO) is a strong message on its is not a priority because they do not get immediate value for own. This is a matter that can be addressed at a global level for money. This is the usual insular reaction based on the idea that the benefit of all and with the support of governments, employers first it is necessary to put home in order before participating to and trade unions (let's not forget ILO constituency).
international activities. Unfortunately there is no evidence that such I will invite the readers to pay attention to the other articles a behavior has been of any help in a crisis situation. On the covering national issues but allowing a perspective from countries contrary in a world that is more and more open, it is important to which are not always on the spot light in their approaches and rely on international organizations to best lever the possibilities solution while they are doing an important work. Iran is from international exchanges. Each large organization can do it on unfortunately well known for the seismic risks it must face and you its own but uniting forces to give a stronger mandate to the IHF is will read how they have prepared themselves to face the next certainly a wise approach for saving money and having a greater disaster. IHF is committed to support the hospital safety program and recommends to rely on the hospital safety index.( The IHF Governing Council has given a new impulse to the organization by reinforcing the role of the IHF secretariat as a Readers will also be interested to see how the most advanced knowledge hub and a resource for advocacy. The Journal will country is facing the need to reconcile telehealth, electronic health evolve by playing a better role in this direction and this issue is records and health information exchange. This perspective is heading toward this direction with articles under the policy section taking us a step forward as each IT innovation is not anymore describing how it is important to work in an international mindset.
considered under its promises but as a piece of a combined Europeans have been making important progresses to deal with approach to address the critical challenges of delivering high cross border healthcare and their example can be a source of quality efficient care.
inspiration for other countries. More and more countries are I am sure that the rest of our selection will capture your attention organizing themselves into regional bodies to deal with supra and would like to remind you that we have an online reader's national issue. The cross border care is a subject of interest in the survey that you are warmly encouraged to fill up. Your feed back Americas, in Africa and in Asia where it is also important to avoid is necessary for us to continuously improve topic and content of duplication of services and better access to care regardless of our articles. Be sure that for the coming year we prepare some national borders, especially when people can easily cross them other changes that will rise up the profile of our Journal by and insurance companies are more and more interested in getting providing more focused articles along with a mainstreamed the best deal for their clients. editorial line… but you will have to wait for next years first edition On another front when countries are considering the possible to learn more about these evolutions. J World Hospitals and Health Services Vol. 46 No. 4 03
04-06 Burger:28 7/1/11 10:49 Page 4 Policy: cross-border projects Striking a balance between nationalinterests and patients' needs: Cross-border projects meetingEuropean challenges THOMAS KOSTERA
GUEST TUTOR FOR "INTERNATIONAL HEALTH CONSULTING" AND RESEARCH AND TEACHING ASSISTANT AT THE INSTITUTE FOR "HEALTH POLICY AND EUROPEAN INTEGRATION" AT THE EUROPEAN STUDIES OF THE UNIVERSITÉ LIBRE DE BRUXELLES UNIVERSITY OF APPLIED SCIENCES IMC AND THE DANUBE IN BRUSSELS, BELGIUM ABSTRACT: The article deals with the new opportunities for EU member state citizens to go abroad for medicaltreatment. The European Court of Justice has facilitated the access to medical treatment for EU citizens in other EUstates. This development has worried national governments since they feared reduced control in their healthcaresystems. The cross-border project "healthacross" between Austria and the Czech Republic however illustrates inwhich way authorities can respond to patients needs in two different countries. Nevertheless a plethora ofadministrative and practical problems have to be solved for cross-border co-operation in the provision of healthcare.
The European Union (EU) is often perceived by citizens as European legal requirements increasing patients' choice some abstract, distant bureaucracy in Brussels. Since Patients might want to seek medical treatment which is usually the Treaty of Maastricht however, different policy fields covered by the domestic health system in other EU member states have become part of the EU's political agenda that have than their home country for various reasons. One underlying rendered the EU much more tangible for citizens. Public health motive is the increased mobility of European citizens due to and healthcare are among these policy fields, they are both retirement of northern Europeans living in Southern Europe, but European issues nowadays. Healthcare has stayed an also because of younger generations using low cost airlines that exclusive member state competence until several landmark have made traveling more widely available to citizens. Furthermore rulings by the European Court of Justice (ECJ) on cross-border the price of an operation can play a role in national systems where patient mobility. These rulings have shown that EU member co-payments are necessary (Rosenmöller, 2006, p.49). A states' healthcare systems and the services they provide have Eurobarometer survey has shown that around half of the European to comply with the fundamental principles of the European citizens in the EU 27 would be ready to travel for medical Single Market. Whereas these rulings have provided European treatment, especially if a certain treatment would not be available citizens with more opportunities to leave their home country in at home (Baeten & Glinos, 2006, p. 6). A second factor is the order to get medical treatment in another EU member state, costs of medical treatments. In some countries dental treatment or national governments are worried about an increasing loss of other medical treatments require quite high co-payments by control over their national healthcare systems. Member states patients. If a patient wants to save money on these co-payments, will have to strike a balance between individual citizens' rights especially treatments in the recently joint member states such as to medical treatment abroad and the states' general interest in Poland, Hungary or Slovenia can be an attractive option for an exit safeguarding the traditional set-up of their healthcare systems.
from the domestic system (Österle, Delgado, 2006, p. 130). In The aim of this article is to illustrate in which way regional these countries treatment is usually available. Some of the patients initiatives can contribute to strike a balance between the who had used this opportunity have sought reimbursement by national and patients' interest by fostering a cross-border co- their domestic healthcare system for their treatment in another operation of local healthcare providers. A planned co- member state. In some cases national legislation did not provide operation on the border between Austria (Lower Austria) and for such a possibility. These patients who had exited their national the Czech Republic (South Bohemia) serves as an example for system used their right to voice their discontent about national striking this balance.
legislation in front of the ECJ. As a consequence the Court has 04 World Hospitals and Health Services Vol. 46 No. 4
04-06 Burger:28 7/1/11 10:49 Page 5 Policy: cross-border projects delivered several landmark rulingsi that have put the "multi-facetedphenomenon" (ibid.) of cross-border patient mobility on the EU's On the Czech side, the provision of agenda. The ECJ ruled that a member state can only restrict the care – especially emergency care – is free movement of patients if these restrictions are objective, non- problematic, at least in the area discriminatory and subjected to possible judicial review. If a close to the border national healthcare system therefore allows seeing any physicianin the home country this now means that patients must have thepermission to see any physician in the EU. Treatment by aphysician in another member state is not subject to priorauthorization anymore, even if only the amount that would have and the ambulance are situated a few hundred metres from the been reimbursed at home will be granted for treatment abroad.
border. Thus the local population of _eské Velenice became Inpatient care remains however subject to prior authorization by already involved in 1999 in the provision of cross-border health the home member state. This permission has to depend on services. In co-operation with the commercial academy Gmünd, objective criteria, and a refusal cannot merely be based on the the hospital Landesklinikum Waldviertel-Gmünd (LK Gmünd) existence of waiting lists in the national healthcare system (Harvey conducted a survey regarding the image of the hospital. Motivated & McHale, 2004, p. 133). These rulings have the potential to by this survey a citizens´ initative was started, resulting in the create an impetus for a common European space of healthcare.
mayor of eské Velenice taking action. He ordered a feasability Former national patients can now play the role of European study for the use of LK Gmünd by Czech patients. The final report consumers in an EU-wide healthcare market and thus force their was issued in 2003. It showed that the acceptance of cross- sickness funds to act accordingly (Sieveking, 2007, p. 40).
border emergency healthcare would be very high. The accession European citizenship now grants patients new social rights when of the Czech Republic to the European Union in 2004 and to the trying to exit their domestic healthcare system. From a member Schengen Agreement in 2008 opened up a large variety of new state perspective however, the tearing down of national opportunities, but created also new challenges especially for boundaries of the healthcare system by European rules gives rise health care. Cross-border co-operation between old and "new" to severe concerns: member states' obligation to reimburse Member States became a realistic option, and funding- patients without prior authorization for medical treatment of a programmes became accessible. Because of the altered situation physician in another member state jeopardizes the national control and the ongoing support of the political authorities in Lower over the consumption of medical services (Lamping, 2005, p. 31).
Austria, the decision was made to start a common initiative for This "decoupling" of medical services from the national territory cross-border co-operation between health care providers in Lower that will occur in some cases also relates to the providers of Austria and South Bohemia. Since also for Austrian patients the healthcare services and is linked to the quality of healthcare. Non- possibility to use healthcare services in specific fields on the other national physicians, pharmacists and nurses from other EU side of the border is of great interest due to shorter distances.
member states should not be hindered anymore to provide their Jindichv Hradec, for example, has a modern dialysis unit that can services on the national healthcare market. Hence, discrimination be easily reached by patients from the Gmünd region. In addition, against these professions in order to protect national providers is there are comprehensive services in the field of rehabilitation in the prohibited (ibid.). The ECJ's rulings and member state Czech Republic that could be used by patients from Lower governments' concerns unsurprisingly have triggered a process of Austria. Therefore, cross-border patient care and exchanges of political discussion and bargaining in Brussels that has been services would be of great advantage for both partners and the lasting now for almost ten years and is still going on. On a more local population In the case of emergency it becomes obvious that practical level, patients needs can not be longer ignored and have for both countries and the regional population a closer co- to be met already. Regional and local health authorities have to operation and better co-ordination of services could bring respond to these needs given the increased willingness of the significant benefits, i.e. the fastest access possible to emergency population in border regions to access medical treatment in a neighboring country. One way of responding actively to these The project-application under the title "healthacross" was demands can be cross-border co-operation as it can be found submitted by Niederösterreichische Landeskliniken-Holding as between the Austrian region of Lower Austria and the Czech lead partner and Jihoeské nemocice, a.s. as project-partner. It Region of South Bohemia.
aims at taking a first step to co-operate between Austria and the In the border region between Lower Austria and South Czech Republic in order to develop an improved access to health Bohemia, the "divided" city of Gmünd/eské Velenice illustrates the care services by all people living in the border region of Lower need for co-operation in the healthcare sector in a particularly Austria and South Bohemia. The innovative nature of the project marked way: on the Czech side, the provision of care – especially stems from the specific situation in that border region due to emergency care – is problematic, at least in the area close to the enormous wage gaps and cost differentials: inequality and border. The next ambulance with physician on duty is stationed at disparity in health status, access to services and the provision of a distance of 17 km in Suchdol nad Lunicí, and the closest treatment have to be addressed. The main objective of hospital is located at a distance of 60 km in eské Budjovice – "healthacross" is thus to facilitate co-operation and to ensure which may result in considerable delays in the provision of medical better access to health care (especially in case of emergency) in care to patients. In contrast, the hospital of Gmünd (LK Gmünd) the area Gmünd/eské Velenice. Furthermore, the optimization andco-ordination of health services in the project region are intended.
The initiative is trying to implement cross-border co-operation in i. Reference in the article is generally made to the following rulings: Kohll, case C-158/96, Vanbraekel, case C-368/98, Müller-Fauré, case C-385/99, and Watts, case C-372/04.
that region for the first time, preparing sound planning schemes World Hospitals and Health Services Vol. 46 No. 4 05
04-06 Burger:28 7/1/11 10:49 Page 6 Policy: cross-border projects and binding rules laid down in bilateral co-operation agreements to ensure that cross-border co-operation will be successful and Baeten, R. & Glinos, I. A. 2006. A Literature Review of Cross-Border Patient Mobility in the sustainable (Burger, Wieland, 2010). A first pilot project has been European Union. EUROPE FOR PATIENTS, ED. Brussels.
started in the field of cross-border emergency care that will be the Burger, R., Wieland, M. healthacross-Report I. Recommendations for Cross-border Health basis for future co-operation and exchange of services. A very Services. 2010, forthcoming Harvey, T. K. & Mchale, J. V. 2004. Health Law and the European Union. Cambridge: Cambridge important element is as well the idea to develop and construct a University Press.
cross-border health centre near the border that is jointly run by Lamping, W. 2005. European integration and health policy. A peculiar relationship. In: both countries. Before setting up such a cross-border health Steffen, Monika, ed. Health governance in Europe. Issues, challenges, and theories. London, New York, NY: Routledge. (Routledge/ECPR studies in European political science; 40), pp.
center several practical problems still have to be addressed by the project: obstacles regarding cross-border patient transfers, Österle, A., Delgado, J., Dental Care Migration in Central Europe, In: BURGER, R., WIELAND, M.
coordinating communication between emergency services, health 2006. healthregio-Report. Economic and Sociopolitical Perspectives for Health Services inCentral Europe providers and hospitals in the regions, the definition of common Rosenmöller, Magdalene, et. al. 2006. Patient Mobility in the European Union: Learning from quality standards and legal coverage of co-operation have to be Experience. Case Studies. Brussels: European Observatory on Health Care Systems / discussed and tackled by the responsible authorities. Thus Rosenmöller, M. Dimensions of "Health Tourism" in Europe. First insights from the e4p CaseStudies. In: Burger, R., Wieland, M. 2006. healthregio-Report. Economic and Sociopolitical "healthacross" put the topic of co-operation on the agenda of Perspectives for Health Services in Central Europe regional politicians, of national stakeholders (e.g. insurance funds) Sieveking, K. 2007. ECJ Rulings on Health Care Services and Their Effects on the Freedom of and will also be a topic of European interest, given that there are Cross-Border Patient Mobility in the EU. European Journal of Migration and Law, 9, pp.
25–51.
regions with comparable challenges in the EU.
ConclusionThe European Court of Justice and its rulings on cross-borderpatient mobility have put healthcare on the European Union'spolitical agenda: a policy field that for a long time has been anexclusive national political domain of EU member states has now tocomply with the legal requirements of the European Single Market.
European patients have been the driving force behind thisdevelopment by not accepting their sickness funds' refusal ofpayment for medical treatment in another EU member state. TheEuropean Court of Justice has considerably enlarged patientchoice and has changed their role from that of a national patientinto the one of a truly European consumer. Furthermore EUmember states have difficulties in adapting to European rules andto find an agreement on a common Directive on the issue: thefreedom of choice for European patients can become burden forseveral national healthcare systems in the EU. Regional cross-border co-operation like the one between Austria and the CzechRepublic shows however that patients' needs can be satisfiedtaking into account the national health systems on both sides of theborder. Such a co-operation even improves access to healthcareand makes way for a new approach to an effective co-ordination ofhealth policy. Nonetheless there are several administrative andpractical obstacles that have to be overcome before a sustainablecross-border provision of healthcare can be set-up. J Renate Burger is currently working for the private companyGesundheitsmanagement Burger-Wieland OG in Vienna (Austria),specialized in project management of cross-border health projectsand health promotion measures in Austria and the EU. She is guesttutor for "International Health Consulting" and "Health Policy &European Integration" at the University of Applied Sciences IMCand the Danube University Krems. Thomas Kostera is currently working as a Research and Teachingassistant at the Institute for European Studies of the UniversitéLibre de Bruxelles in Brussels (Belgium). He is writing his PhD oncross-border patient mobility in the EU and holds a Master'sdegree in European Political Studies from the College of Europe,Bruges (Belgium) and a degree in Administrative Science from theUniversity of Potsdam (Germany). 06 World Hospitals and Health Services Vol. 46 No. 4
07-12 Najafbagy:28 7/1/11 09:32 Page 7 Management: crisis management Crisis management, capabilities andpreparedness: the case of publichospitals in Iran DR REZA NAJAFBAGY
DIRECTOR OF THE PHD PUBLIC ADMINISTRATION PROGRAM, FACULTY OF MANAGEMENT AND ECONOMICS, SCIENCE AND RESEARCH BRANCH, AZAD UNIVERSITY – TEHRAN, IRAN ABSTRACT: Crises occurred in recent decades show that organizations' preparedness to predict and respond to undesired problemsis directly related to the degree of their capabilities and preparedness to manage crises in this context, hospitals compared to otherorganizations are more viable to suffer damages if a crisis occurs. This study investigates the degree of public hospitals capabilitiesand preparedness to handled possible crises. Responses from hospital managers and directors show that most of them were notfamiliar with crisis management, while majority of them mentioned that they had crisis management plan and committee in theirhospitals. Moreover, most of the respondents believed that if a crisis occurs in the hospital, patients, personnel and documents willbe the first victims of the crisis. The study also indicates that having a crisis plan and crisis committee without being familiar withknowledge of crisis management, do not help managers to cope with crisis. Moreover, correlations show that older managers weremore familiar with crisis management experiences abroad, and defined responsibilities contributed to setting up crisis committee,and taking crisis seriously.
Crisis can be simply defined as a situation which is not Types of crisis possible to maintain. Therefore, when a crisis occurs, a We should be familiar with types of crisis, because each crisis change is required until we reach balance and equilibrium.
requires a different strategy to handle. There are many types of In fact, if there would be no need for a change in the situation, what has happened could be regarded as an accident or an event,  natural crisis such as earthquake, floods, and storm; like a car crash. In other words, a crisis is a process that an  crisis of malevolence, such as hostility or anger toward, or organization may face during an unexpected threat which may seeking gain from, a company as happened in Johnson and lead to organizational damage. Crisis management is the process Johnson in 1982 in America. A Tylenol medication, by which an organization deals with a major unpredictable event unfortunately, one individual succeeded in lacing the drug with that threatens to harm the organization, its stakeholders, or the cyanide and seven people died as a result, and a widespread general public. Crisis management is the systematic attempt to panic ensued about how widespread the contamination might avoid organizational crisis or to manage those crisis events that do occur (Pearson & Clair, 1998). In fact, crisis management is a  the crises in hospital emergency departments; technique both for avoiding emergencies and planning for the  events occurring due to negligence such as the Bhopal unavoidable ones, as well as a method for dealing with them when disaster in 2006 in India; they occur (Yheung et al., 2003). Crisis is a major, unpredictable  crisis due to human error, such as mistakes in software or event that threatens to harm an organization and its stakeholders.
hardware, or calculation mistakes in building wiring installation; Although crisis events are unpredictable, they are not unexpected  strikes or work stoppage or when workers rebel against (Coombs, 2004). Three elements are common to most definitions employers of organizations;  schools and crisis management; The Beslan school hostage  a threat to the organization; crisis (also referred to as the Beslan school siege or Beslan  the element of surprise; massacre) was a three day hostage-taking of over 1,100  a short decision time.
people which ended in over 300 deaths. The Iran hostagecrisis (4 Nov. 1979–20 Jan. 1980) Following the establishment The true test for any hospital executive lies in managing a crisis.
of the Islamic Republic of Iran.
A hospital crisis, by definition, is unexpected and unpleasant. No  Economic recessions (in 2009, for instance).
organization seeks it out; no CEO desires to face it. It is the job ofa CEO to be prepared for sudden crisis and to manage them.
In fact, the concept of a crisis portfolio can aid managers World Hospitals and Health Services Vol. 46 No. 4 07
07-12 Najafbagy:28 7/1/11 09:32 Page 8 Management: crisis management significantly in planning for crisis (Lichtenthal and David, 1999).
government and the public-at-large. First, one must recognize the The essential part of any crisis is to handle it successfully.
"warning signs" that almost invariably emerge when a crisis is Therefore, crisis management is a combination of procedures and near (Coombs, 1995).
actions, which in emergencies, are applied in order to handle the Barton (2001) says that forecasting plans are successful when crisis in a planned and coordinated manner. Crisis management is (1) organizations yearly set awake a crisis plan, and update it, (2) an operational plan, and is designed to be executed when the the plan includes loyal and advocated key personnel, and (3) the organization faces an unusual situation or, crisis management is a plan is practiced yearly. In all three types of (plans) crisis, there process designed to prevent or lessen the damage a crisis can should be one person as management spokesperson, because, in inflict on an organization and its stakeholders. We can compare the crisis, there is a serious need to prevent crisis news distortion, crisis management with "risk management." Risk management because consistency in news broadcasting is vital. Being ready to involves assessing potential threats and finding the best ways to face a crisis, strong coordination and cooperation among groups avoid those threats, but crisis management involves dealing with and individuals are very important to deal with a crisis. Proper and threats after they have occurred, which is an evaluation correct training (specialized and general), and appropriate concerning possible threats to the institution, and an attempt to equipment are two main components of facing a crisis. In addition, find the best way to face the threat. Risk assessment is an information given to the public should be accurate, honest and on intrinsic function of the risk-management process and time. In a study done at the Faculty of Management at Tehran subsequently risk assessment also has become a core part of University on crisis management to find out priority of actions emergency management (Jones, 2008). In reality, crisis during a crisis, the following information was provided by the management encounters different types of problems and threat compared to risk management, but it is much broader in that and  Try to find those who are alive, and treat them as they its dimensions are much wider such as skills and techniques which are used for recognizing, evaluating and eventually facing  Coordination among the teams of the crisis.
different situations, particularly from the time that crisis occurs,  Operation of various groups involved in the crisis.
until it moves towards improvement.
 Machines and equipment.
 Finding or setting up connecting roads.
Stages of crisis management  Settlement of those who can be settled and hospitalizing Organizational safety is the top priority of every manager.
those who need it.
Moreover, facing any crisis successfully is extremely important, but  Taking care of security in the area affected with the crisis.
predicting and being ready to respond any crisis is very essential.
 Applying what has been learned from international Therefore, crisis management can be divided into:  Forecasting or overseeing a crisis (before any crisis happens).
 Setting up communication.
 Being ready to face a crisis or respond to a crisis.
 Air lift or air help.
 Proceeding through, or actions after, a crisis.
 Receiving goods and other help and distributing them among the people who need these goods and help.
Preparedness, is a fundamental step for any organization in  Temporary settlement of those who are alive.
order to handle a crisis whenever it occurs. In fact, being prepared  Setting up a telephone communication network.
to face a crisis means that the organization has reduced the risk  Burial of dead.
of losses and damages when a crisis occurs. In fact, prevention  After crisis is a complicated, sensitive and difficult stage to be involves seeking to reduce known risks that could lead to a crisis handled. In a crisis such as an earthquake, individuals try first (Augustine, 1995). This is actually a part of crisis-management to save themselves, then take care of others. But right after planning. Therefore, planning involves advanced thinking and this stage, they try to search for their belongings, documents designing methods for dealing with a crisis in appropriate steps to and property.
not only handle the crisis, but to reduce damages to theorganization as much as possible. In the forecasting stage, Priorities of actions or proceedings after the crisis are as follows: finding out the weak points or potential threats to the organization  Settlement of children and survivors.
is essential. Appointing key individuals for setting communication  Organizing and distributing national and international aid.
channels during the crisis is the next step. The essence of the  Using social workers and providing psychological advice.
practice of public relations is dealing with the media. Therefore, the  Applying international experiences.
responsibilities of key individuals should be assigned.
 Collecting debris and destroyed buildings.
Communication must be open, honest and consistent. Because  Reconstruction of the region.
all actions during the crisis must be documented, forms to make  Transferring those who lost their houses to the newly built records during the crisis should be prepared. This is followed by houses (Taslimy et al., 2005).
the training of key personnel and running simulation programmesto find out whether forecasting plans are feasible and applicable.
Boin (2004) indicates that crisis authorities must identify which Recognizing a crisis is very vital. How an organization, decisions they must make and which should be left to others.
particularly a hospital, handles crises may influence how the public They must make critical decisions without sufficient or adequate perceives the organization for many years to come. It is therefore information. They must enable cooperation between the various essential that such emergencies be managed intelligently and factors involved, and they must organize communication streams forthrightly with the news media, medical staff, employees, the within and across the crisis management network as well as with 08 World Hospitals and Health Services Vol. 46 No. 4
07-12 Najafbagy:28 7/1/11 09:32 Page 9 Management: crisis management the outside world.
Table 1: Familiarity of respondents with crisis management Theories associated with crisis managementSuccess in neutralizing or facing a crisis depends on how well we Degree of familiarity are aware of preventing a crisis such as Tsunami, floods following storms, which brings destruction. Successfully diffusing a crisis Not very familiar requires an understanding of how to handle a crisis before it occurs. Gonzalez-Herrero and Pratt (1995) created a four-phase crisis management model process that includes: issues management, planning-prevention, the crisis, and post-crisis. Theart is to define what the crisis specifically is, or could be, and what Table 2: Crisis management plan in the hospitals has caused it or could cause it. Crisis management has threestages: (1) management issues, (2) planning for preventing crisis,and (3) and issues after crisis. The skill involved in implementing this crisis management is that we must know the type of crisis, what has caused it, or what could cause it. Mayer et al. (2008) have identified specific areas that should be addressed in a crises and disaster preparedness plan based on information gathered from organizations that went through a major disaster first-hand.
Crisis-management planning is necessary for any kind of crisis, Table 3: Number of hospitals with crisis management committee but organizations cannot sit and wait until a crisis occurs and thendeal with it. "Companies are beginning to realize that what happens to a Union Carbide can happen to them, whether they'rebig or small, publicly traded or privately held" (Rudolph, 1986).
Contingency plans in advance, as part of a crisis-management plan, are the first step to ensuring a hospital is appropriatelyprepared for a crisis. Actually, a crisis management plan is areference tool, not a blueprint. It provides lists of key contact Table 4: Possible crisis in hospitals and effective factors to face it information, reminders of what typically should be done in a crisis,and forms to be used to document the crisis response (Coombs, 2007). Tasks should be clearly defined and assigned in advance.
Any distorted information based on personal opinion, i.e., whether a person may be responsible or irresponsible in a crisis, may result Coordination between authorities Having a committee comprised of in chaos. In healthcare systems, most healthcare professionals, members of all sections whether board members, managers, or physicians, generally Applying instructions already formulated by would say that the environment they face today is much more the Ministry of Health uncertain than it was even five years ago (Barnum and Kutzin, Following crisis management standards Applying successful past experiences 1993). The last point which is vital to mention is the readiness of employees of an organization to face a crisis which requires effective crisis management (Seymour and Moore, 2000).
Case study: hospital crisis management, capabilities and Table 5: In case of crisis, and damages in the hospital preparedness in Iran – purpose and objectivesThe goal of this article is to present the findings from an exploratory empirical study of hospitals' capabilities andeventually their preparedness to face crisis, if it occurs in their hospitals. Below we have presented short general country information as the background data which may contribute to better understanding of this article.
MethodIn Iran, there are 856 hospitals (governmental and private) of cumulative and correlations have been used.
which I have concentrated only on 121 hospitals (65governmental and 55 private) located in Tehran (the capital). A Research question and samples sample of 41 hospitals (out of 121) were selected, and I The main reason to concentrate on governmental (or public interviewed all of either hospital directors 31 (76%) or hospital hospitals) in relation to private ones, is that in most public managers 10 (24%). Most hospitals have a senior doctor as the hospitals, some are not as equipped and modern as private head of the hospital (director), and some have hospital managers.
hospitals, and they are more vulnerable to crisis. The main For statistical analysis of data, frequency, percentages, research question is: Are governmental hospitals capable and World Hospitals and Health Services Vol. 46 No. 4 07
07-12 Najafbagy:28 7/1/11 09:32 Page 10 Management: crisis management Table 6: Familiarity with handling crisis management in Iran and crisis management? experiences abroad As the above table shows, around 40% of the respondents seem to be familiar or very familiar with crisis management.
2. Is there a crisis management plan in your hospital?Table 2 shows that almost 95% of respondents mentioned that Age groups very familiar fairly familiar not very familiar their hospitals have a crisis plan. However, this statementcontradicts with responses on familiarity with crisis management of which around 58% of the respondents believed that they are 18 (44%) 3 (7.%) either "not familiar" with the subject of "crisis management" or "very little" are familiar.
3. Is there a crisis committee in your hospital with clear function 4. For facing crisis in a hospital, what factors could be very Table 7: The relation between age groups and familiarity with helpful and effective? crisis management The above table shows inconsistency among the responses.
Moreover, out of 41 respondents, 10 have not responded to this 5. Is there a possibility of a crisis in your hospital? Out of 41 respondents, 36 of them replied: yes (85.4%) and 6 Not so much familiar said: no (14.6%) This shows that there is a high risk of crisis in Very little familiar 6. In case a crisis occurs in your hospital, what sources might be harmed or face damages? Table 9 shows that in case of crisis in hospitals, personnel and prepared to predict and face crisis? This quantitative exploratory documents seem to be more vulnerable compared to even study utilized a closed-ended questionnaire and all respondents were interviewed. In this case, out of 41 respondents, 30 were 7. To what extent are you familiar with hospital crisis surgeons, and 11 were professional managers (with MA or PhD management in Iran and in other countries? degree). The questionnaire was divided into two parts: (1) personal It seems that majority of the respondents are familiar with the data, and (2) management data. At the end of the questionnaire subject of crisis management in Iran and abroad. We also tried to we added one open question to obtain extra information.
see whether there was a relationship between age and familiaritywith crisis management. Managers under 35 and those above 45 years of age were not very familiar with crisis management, while The first part of the questionnaire included "personal data" of the those between 35 and 40 years of age seem to be very familiar or respondents which shows gender, education, age groups and fairly familiar with crisis management.
length of service, discussed below. As we mentioned earlier, at the end of the questionnaire, we Out of 41 hospital directors and managers, 8 were women added an open question in order to find out extra information (19.5%), and 33 were men (80.5%). This indicates that almost one which the respondents might like to express. Table 8 illustrates fifth of them were women which might be due to the nature of the their reactions.
job and type of hospitals which are governmental. More than 50% The above table indicates that among factors which seem to of the respondents hold MA and PhD degree, around 60% were have effects on hospitals' crisis management, budget limitation is between 35 and 45 years of age, which is an indication that the most common factor. Further statistical analysis was carried hospital mangers in the coming years seem to be available, and out, and correlations between factors showed that managers 57% had less than 10 years of service. who were older, had higher level of education. On the contrary, Tables 1 through 9 include questions related to respondents' women mangers who were older, had lower level of education.
capabilities and hospitals preparedness to crisis.
Length of service showed strong correlations with age. It seems 1. To what extent hospital managers in Iran are familiar with that age has played a key role in this study, because the older the managers, the more they Table 8: Hospital managers' extra comments on crisis management issues considered crisis serious.
There was also strongcorrelation between those who had received training on Possibility of more crisis in hospitals due to limitation of facilities crisis management and Limited budget devoted to hospital crisis, and lack of top management support responsibilities during crisis Low motivation among hospital personnel, and lack of proper training defined. Age played important Strong need to design crisis management plan as a compulsory task of hospital managers 2.00 Lack of utilizing other experiences, and lack of communication between hospitals role on being familiar with crisis Lack of skilled personnel in handling crisis in other countries. Length of service seems to have impacton familiarity with crisis in 10 World Hospitals and Health Services Vol. 46 No. 4
07-12 Najafbagy:28 7/1/11 09:32 Page 11 Management: crisis management Table 9: Cross tabulation correlations Correlations
Spearman's correlation (Q 1) Correlation Coefficient 1.000 Correlation Coefficient -.379* Correlation Coefficient .423** Length ofService(Q4) .000 .093 .018 .
Taking crisis seriously(Q 5) Correlation Coefficient .431** .005 .108 .306 .094 .
Whether crisis planexists(Q .173 -.174 -.028 .115 .345* 1.000 .280 .276 .863 .481 .029 .
41 41 41 40 40 41 Training on crisis givenor not(Q .179 -.049 .270 .608** .922 .014 .261 .763 .092 .000 .
Responsibilities defined(Q .125 -.047 .282 .689** .729 .002 .435 .773 .078 .000 .000 .
Familiarity with crisis in other countries(Q .134 .303 .736** .280 .296 .225 1.000 .001 .031 .402 .058 .000 .077 .060 .158 .
Existence of crisis committee(Q .034 -.046 .302 .804** .866 .031 .842 .794 .073 .000 .000 . *. Correlation is significant at the 0.05 level (2-tailed).
**. Correlation is significant at the 0.01 level (2-tailed).
other countries. Having crisis committee in the hospital was also management plan in their hospitals, and have set-up crisis- strongly related with being trained in crisis management.
management committees. Most managers believed that if a crisisoccurs in their hospitals, the existence of a crisis-management committee and certain standards are the most effective factors In this study, we have tried to study managers' capabilities and which could help them to face the crisis. In reply to the possibility preparedness to face crisis in state hospitals if it occurs. We have of a crisis in hospitals, the majority of respondents reacted also studied factors which could contribute to reveal certain positively. In case of a crisis, patients would be the first target to be information related to crisis management and perception of harmed, and next would be the hospital personnel. Most hospital mangers of hospitals under the study, their knowledge and managers seemed to be familiar with handling a crisis, and familiar experiences on crisis management. The data shows that majority with experiences on this issue in Iran and abroad. The study shows of hospital managers were not familiar with crisis management, but that there was a relationship between age and familiarity with crisis on the contrary, 95% of them mentioned that there was a crisis- management. In fact, managers under 35 and those above 45 World Hospitals and Health Services Vol. 46 No. 4 11
07-12 Najafbagy:28 7/1/11 09:32 Page 12 Management: crisis management years of age were not very familiar with crisis management, while those between 35 and 45 years of age seems to be very familiar Augustine, N.R. (1995). "Managing the crisis you tried to prevent," Harvard Business Review, or fairly familiar with crisis management. Correlations show strong 73(6), pp. 147-158.
relationship between length of service and taking crisis seriously, Barnum, H. and J. Kutzin (1993). Public hospitals in developing countries: resource use, cost, defined responsibility and training. J financing, Baltimore: John Hopkins University Press, p. 335.
Barton, L. (2001). Crisis in Organizations (2nd ed.) Cincinnati, OH, (USA), College Divisions South- Western, pp. 14-17.
Reza Najafbag received his PhD from Utrecht State University-the Boin, A. (2004). "Lessons from Crisis Research," International Studies Review, 6, pp.165-175.
Netherlands, in Comparative Management. and has more than 30 Coombs, W.T. (2007). "Crisis Management and Communications," Inst. for Public Relations,Eastern Illinois University, pp. 1-17.
years of continuous teaching and research experience. He has -----------(2004). "Structuring crisis discourse knowledge: The West Pharmaceutical case," organized and planned academic programs and activities on Public Relations Review, 30, pp. 467-474.
leadership are performed executive and management training -----------(1995). "Choosing the right words: The development of guidelines for the selection of the "appropriate" crisis response strategies," Management Communication Quarterly, 8, programs. He is a personnel management advisor to Coopers & pp. 447-476. Gonzalez-Herrero, A & C.B. Pratt (1995). "How to manage a crisis before or Lybrand-Iran. (Management and accounting multinational firm). whenever – it hits," Public Relations Quarterly, 40, pp. 25-30.
Health care in Iran, at http://en.wikipedia.org/wiki/Healthcare in Iran, accessed 20 April 27, 2007,Iran: Healthcare and Pharmaceuticals Forecast", Economist Intelligence Unit, August18, 2008.
Jones, T. (2008). "Advances in risk assessment for Australian emergency management," The Australian Journal of Emergency Management, 23(4), p. 4.
Lichtenthal, H.P. and J. David (1999). "Anatomy of organizational Crises," Institute for the study of Business Markets (ISBM,) Report 28, pp. 13-15.
Mayer, B. , W. Mayer, J. Moss and K. Dale (2008). "Disaster and Preparedness: Lessons from Hurricane Rita," Journal of Contingencies and Crisis Management, 16, pp. 4-23.
Pearson, C.and J. Clair (1998). "Reframing Crisis Management," Academy of Management Review, 23(1), pp.59-76.
Rudolph, B. (1986). "Coping with catastrophe," Time Journal, February, p. 53.
Seymour, M. and S. Moore (2000). Effective Crisis Management, Cassell, London and New York. Taslimy, M., M.A. Emadi, M. Barghi, and T. Roshandel Arbatani (2005). "Prioritizing,crisis, natural disaster, crisis cycle, analytical hierarchical process (AHP), Delphi, Technique,"Journal of Daneshe Modiriat (Management Knowledge), 69. Pp. 23-33.
The World Bank, Country brief, Iran, at; Yheung, A., M. Sau-mui, L. Pui-shan and L. Yau-wai (2003). "Crisis Management Model, Managing SARS," Hong Kong Polytechnic University, Group paper.
http://www.glocom.org/debates/20030403 yheung sars/issued on April 3,2003.
12 World Hospitals and Health Services Vol. 46 No. 4
13-16 Frampton:28 4/1/11 13:10 Page 13 Management: patient care Patient-centred care: more than thesum of its parts – Planetree'spatient-centred hospital designationprogramme SUSAN B FRAMPTON PhD
PRESIDENT, PLANETREE IN DERBY, CT MANAGER OF DESIGNATION AND RESOURCE DEVELOPMENT, PLANETREE IN DERBY, CT ABSTRACT: When a nurse at the Celilo Cancer Center at the Mid-Columbia Medical Center in The Dalles, Oregon, found out that hispatient was scheduled to receive chemotherapy on her wedding anniversary, he asked the woman and her husband what songthey'd first danced to on their wedding day. It was "Save the Last Dance For Me," and the next day, when the couple rose fromtheir chairs after the patient's six-hour infusion, the song began playing. Right there in the infusion area, with their arms aroundeach other, they danced. This story illustrates the kind of care that has become the norm at the 10 hospitals in North America recognized since 2007 as patient-centred hospitals by Planetree's Patient-Centred Hospital Designation Program. At these hospitals "patient-centred care"is more than a buzzword. Rather, it's reflected in their mission statements, strategic plans, models of nursing care, and day-to-dayoperations. While many organizations, including the Institute of Medicine,1 the Institute for Healthcare Improvement,2 and Planetree,3 have endeavored to define patient-centred care, no definition conveys its essence as well as the patients at these hospitals can. "Thisplace has a special character," one patient said in a focus group. Others have said, "You can tell the nurses here care about you asa person," "They are a special breed of people here," and "I don't think it's just a job for them; they're here for a reason." Over the past year, this series, Putting Patients First, has explored several aspects of the patient-centered approach – encouragingpatients to review their medical records, lifting restrictions on family involvement in care, and lowering noise levels in hospitals,among others. We believe they show that, ultimately, patient-centered care is more than the sum of its parts. Planetree's goal with the designation program is to make three decades of work with hospitals in the United States and patient-centred care less of an ambiguous notion and more abroad, especially data gathered from focus groups conducted of an attainable goal (for more information, go to with thousands of patients, family members, and healthcare http://planetree.org/consultation.html). Many facilities have professionals. Using these perspectives, Planetree shaped 50 aspired to become more patient centred as the concept has criteria for designation in 11 categories (see Table 1).
garnered attention in recent years. The Hospital Consumer Criteria include whether hospitals balance patients' needs with Assessment of Healthcare Providers and Systems (HCAHPS) their safety, whether transparency remains a priority even when survey, for example, compiles patients' assessments of something unexpected occurs, whether the work environment ishospital care and makes them available online (see supportive of staff, and whether patient-centred approaches are www.hospitalcompare.hhs.gov). Also, the major health care applied to billing and community outreach. Community outreach reform legislation passed this year includes financial incentives to at Griffin Hospital in Derby, Connecticut, for example, includes its hospitals that meet certain standards of patient-centeredness, Mini Med School, a free 10-week class in which volunteer "such as the use of patient and caregiver assessments or the use physicians present lectures on illness and prevention, while of individualized care plans."4 encouraging "students" to participate in their care.
Still, there's a gap between aspiration and reality at many The designation is granted to hospitals that meet all 50 criteria.
organizations when it comes to patient-centredness. The The process begins with a self-assessment that requires hospital designation program provides a framework for evaluating the a leaders to appraise the organization's culture – an appraisal that hospital's systems and processes, one that's based on Planetree's can be valuable, regardless of whether it's part of the designation World Hospitals and Health Services Vol. 46 No. 4 13
13-16 Frampton:28 4/1/11 13:10 Page 14 Management: patient care process. After all, Planetree designation recognizes a job welldone, not a job all done. (Designation lasts for three years.) The Planetree program's emphasis After the self-assessment, a hospital provides to Planetree on relationships can help to remind documentation of its patient-centered practices. Next, a team nurses of what drew them into the including representatives of facilities that have achieved profession, especially when the designation make an on-site visit; the written documentation is entire organization is committed to verified through a facility tour and feedback from patients, family supporting nurses' adoption of members, and staff. This team's assessment is then reviewed by an independent committee of healthcare leaders, withrepresentatives from the American Hospital Association, theInstitute for Healthcare Improvement, and patient advocacygroups, among others. This feedback informs a decision to disconnected from relationships and caring."6 The Planetree designate a hospital as patient-centred.
program's emphasis on relationships can help to remind nurses of Involving patients, family members, and staff in the assessment what drew them into the profession, especially when the entire supports a facility's efforts to foster a patient-centered culture. At organization is committed to supporting nurses' adoption of the on-site visit at Northern Westchester Hospital in Mount Kisco, patient-centered practices. "For me," one nurse said in a focus New York, for example, it was revealed that although the hospital group, "it's returning back to what nursing was when I started. It's had in place a number of means for meeting patients' nutritional being able to have the time to spend with patients and families, to needs, patients were largely unaware of their options.
do the little back rubs we used to do, to give that little bit more of Consequently, the Just Ask Campaign was born. Now, signs yourself. We're saying to nurses that you do have time for that." assure patients: "If you're thinking it, ask it." Examples of Nurses have long championed patient-centered care and questions include, "May I request a different meal selection?" continue to study its value. Susan Stone, former chief nursing Patient-centred care requires flexibility and discourages a one- officer and chief operating officer at Sharp Coronado Hospital in size-fits-all approach. For instance, despite a policy in support of Coronado, California, engaged the nursing staff there in meeting open medical records at Waverly Health Center in Waverly, Iowa, the designation criteria and conducted research on the impact of only a few Waverly patients reviewed their charts. The hospital patient-centered care in the facility. The study retrospectively sought out an alternative and created the Personal Health examined data from two comparable medical-surgical units over Information notebook, given to every medical–surgical patient.
five years—one that had implemented the Planetree model and Over the course of a hospitalization, the notebook accumulates one that had not.7 In each of the five one-year cohorts studied, the laboratory results, medication lists, consultation reports, and Planetree unit consistently demonstrated: DVDs of scans. The hospital gets the notebook into the hands of  shorter average lengths of stay; a far greater number of patients than it did the medical record.
 statistically significant lower costs per case (an increase in RN hours per patient day was augmented by a simultaneous The role of nurses increased use of "lower-cost personnel" such as aides; shorter Everyone working in a healthcare facility can contribute to a hospitalizations also led to decreased costs); patient-centred approach – by keeping it safe and clean if they  higher average overall patient-satisfaction scores; work in environmental services, for example, or by preparing  higher scores in seven of the nine dimensions of patient healthful foods if they work in dietary services. Yet partnerships satisfaction measured. between nurses and patients are a cornerstone of patient-centered care. This is reflected in the questions on the HCAHPS When bedside staff appear to be burdened, patients notice, and survey, which includes patients' perceptions of nurses' they might, as a result, hesitate to ask for help or make their needs communication and responsiveness.5 A number of the designation known.8 As one patient in a focus group said of a nurse, "I asked criteria also focus on the involvement and leadership of nurses, for her about getting a pain medication. She responded in a rude example, in their support of family members as "care partners" manner—‘You didn't have that pain med.' I gave them the benefit who participate in care.
of the doubt that they were having a bad day, that they were As nursing theorist Jean Watson, PhD, RN, has written: "Clinical overworked." Nurses and consumers alike have identified care and healthcare practices are grounded in human overworked, fatigued staff as contributing to the potential for communication, human interactions and relationships. At the medical errors.9, 10 same time, approaches to system solutions are often Given the alarming rates of turnover,11 vacancy,12 and burnout13- 15 among nurses, the experience of staff is a critical considerationin the Planetree designation. Giving bedside staff rewards andrecognition, retreats, access to minutes of leadership meetings Everyone working in a health care and other information on organizational priorities, a say in howcare is delivered, and services supporting work–life balance are facility can contribute to a among the ways that hospitals uplift staff while putting patients patient-centered approach – by first. Griffin Hospital, for instance, makes an on-site fitness center keeping it safe and clean if they available to staff, sponsors a farmer's market at the facility during work in environmental services the summer, and offers prepackaged "meals to go" in its cafeteria.
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13-16 Frampton:28 4/1/11 13:10 Page 15 Management: patient care Table 1: The patient-Centred hospital designation program: American Nurses Credentialing Center in recognition of nursing categories and selected criteria excellence at Delnor Hospital in Geneva, Illinois. Also, GriffinHospital appeared on Fortune magazine's 100 Best Companies toWork For in the United States from 2000 to 2009, and in 2009 Structures and functions necessary Processes are in place to obtain and Centre de réadaptation Estrie, a rehabilitation hospital in Quebec, for implementation, development, use feedback from patients and was recognized in Canada's Les Affaires magazine's Best and maintenance of patient- families on a variety of hospital practices centred concepts and initiatives.
On its Quality Check Web site (www.qualitycheck.org), the Joint Human interactions A model that embraces continuity, consistency Commission recognizes hospitals that have received the Planetree and accountability in care and permits staff to designation. Planetree-designated hospitals have been featured in personalize care for each patient.
the Washington Post16 and the New York Times.17 But thegreatest benefits have little to do with publicity. Marcia Hall, CEO Patient education and access Educational materials available for patients and families and accessible to staff.
of Sharp Coronado Hospital in Coronado, California, said: "We areextremely proud of becoming one of the first five nationally noted Family involvement Flexible, 24-hour, patient-directed visitation.
Planetree Designated Patient-Centered Hospitals. But it's notabout awards. They confirm that we're on the right track, but it's Nutrition programme 24-hour access to a variety of foods and mostly about progress toward a vision to make a difference for the people we work with and the people that we serve." Healing environment: architecture Removal of barriers at nurses' stations such as and interior design high counters and counter-to-ceiling glass partitions, as well as those at family lounges, When Planetree launched it in 2007, the designation program was specific to acute care hospitals. Since then, advisory councils in A therapeutic-distractions programme involving behavioural health and continuing care have worked to revise the music, visual arts, crafts, animal visitation, designation criteria so that they're applicable to a greater range of settings. The new criteria establish a consistent set of standards Spirituality and diversity Documenting and addressing the needs of for what consumers can expect from any patient- or resident- centred provider.
Also, an International Designation Advisory Council is shaping a Integrative therapies Assessment of staff and patient interest in and set of international criteria that are globally applicable. Designation need for alternative, complementary, and programs are under way in Canada and the Netherlands and indevelopment in Brazil and Japan.
Healthy communities A plan to improve community health.
The designated hospitals Satisfaction of inpatients and outpatients assessed using a validated instrument, with As of June, Planetree had designated the following 14 healthcare organizations as patient-centered: Centre de Réadaptation Estrie, Sherbrooke, QC, Canada; Delnor Hospital, Geneva, IL; Connecting patient-centredness and quality  Fauquier Hospital, Warrenton, VA; Care safety and quality go hand in hand in any patient-centred  Griffin Hospital, Derby, CT; approach. Accordingly, Planetree evaluates outcomes as a part of  Mid-Columbia Medical Center, The Dalles, OR; the designation process by comparing a hospital's scores with  Northern Westchester Hospital, Mount Kisco, NY; national benchmarks. We've found that collectively the 10  Sharp Coronado Hospital, Coronado, CA; designated hospitals exceed the Centers for Medicare and  Valley View Hospital, Glenwood Springs, CO; Medicaid Services (CMS) national averages on several "core  Waverly Health Center, Waverly, IA; measures" such as pneumonia care (see Figure 1). This conforms  Windber Medical Center, Windber, PA; to the Institute of Medicine's conclusion that patient-centred care  Longmont United Hospital, Longmont, CO; is a part of the foundation of high-quality care.1 Also, as a group  Judith Leysterhof (Rivas Zorggroep), Hardinxveld-Giessendam, the nine US designated hospitals perform above the CMS national average in nine of the 10 publicly reported HCAHPS categories  De Merlinge (Rivas Zorggroep), Arkel, The Netherlands; and at the national average for the "quiet at night" category (see  De Toonladder (Zorggroep Almere), Almere, The Figure 2). The most significant differences appear in the overall rating and in willingness to recommend the facility, suggesting alink between patient-centered care and patient satisfaction.
Susan B Frampton, PhD is President of Planetree, a non-profitorganization, Frampton works with a growing network of hospitals The benefits of designation and health centres around the world that are implementing Accolades received by the designated hospitals include the 2007 Planetree's unique patient-centered model of care. Prior to her Malcolm Baldrige National Quality Award, a presidential award for work with Planetree, she spent over 20 years at several hospitals in excellence given to the Sharp Healthcare System, which Sharp the New England area. She has written numerous publications, is a Coronado Hospital is a part of, and Magnet accreditation from the sought-after keynote presenter and serves on expert advisory World Hospitals and Health Services Vol. 46 No. 4 15
13-16 Frampton:28 4/1/11 13:10 Page 16 Management: patient care panels for the Institute of Medicine, Joint Commission and NationalQuality Forum. Sara Guastello oversees the Planetree Designation Program whichformally recognizes hospitals and healthcare centers that areeffectively identifying and responding to the full range of patient,family and staff needs. Sara collaborates and consults withPlanetree members and other partners to expand understanding ofpatient- and resident-centered approaches to care throughdevelopment of a variety of resources. 1. Institute of Medicine. Committee on Quality of Health Care in America. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academy Press;2001. http://www.nap.edu/books/0309072808/html.
2. Institute for Healthcare Improvement. Patient-centered care: general. n.d.
3. Frampton SB, Charmel PA, editors. Putting patients first: best practices in patient-centered care. 2nd ed. San Francisco: Jossey-Bass; 2008.
4. The patient protection and affordable care act. 111th Congress, 1st session ed. 2010.
5. Centers for Medicare and Medicaid Services. Hospital compare. 2010.
6. Watson J, Frampton SB. Human interaction and relationship-centered caring. In: Frampton SB, Charmel PA, editors. Putting patients first: best practices in patient-centered care. SanFrancisco: Jossey-Bass; 2008. p. 3-26.
7. Stone S. A retrospective evaluation of the impact of the Planetree patient-centered model of care on inpatient quality outcomes. HERD: Health environments research and design journal2008;1(4):55-69.
8. Frampton SB, et al. Patient-centered care improvement guide. Derby, CT; Camden, ME: Planetree, Inc.; Picker Institute; 2008 Oct. http://www.planetree.org/Patient-Centered%20Care%20Improvement%20Guide%2010.10.08.pdf.
9. Buerhaus PI, et al. Is the shortage of hospital registered nurses getting better or worse? Findings from two recent national surveys of RNs. Nurs Econ 2005;23(2):61-71, 96, 55.
10. Kaiser Family Foundation, Agency for Healthcare Research and Quality, Harvard School of Public Health. National survey on consumers' experiences with patient safety and qualityinformation. Washington, DC; 2004 Nov. http://www.kff.org/kaiserpolls/pomr111704pkg.cfm.
11. Kovner CT, et al. Newly licensed RNs' characteristics, work attitudes, and intentions to work.
Am J Nurs 2007;107(9):58-70; quiz -1.
12. American Hospital Association. The 2007 state of America's hospitals—taking the pulse.
Findings from the 2007 AHA survey of hospital leaders [PowerPoint presentation].
Washington, DC.
http://www.aha.org/aha/content/2007/PowerPoint/StateofHospitalsChartPack2007.ppt.
13. Erickson RJ, Grove WJC. Why emotions matter: age, agitation, and burnout among registered nurses. Online journal of issues in nursing 2008;13(1).
14. Vahey DC, et al. Nurse burnout and patient satisfaction. Med Care 2004;42(2 Suppl):II57-66.
15. Aiken LH, et al. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA 2002;288(16):1987-93.
16. McAteer MJ. Virginia hospital treats the whole person. Washington Post 2009 Mar 24.
17. Lombardi, KS. For patients, more comfort and a bigger dose of respect. New York Times 16 World Hospitals and Health Services Vol. 46 No. 4
17-23 Thielst:28 7/1/11 09:37 Page 17 Management: ehealth At the crossroads: NRTRCwhite paper examines trendsdriving the convergence ofTelehealth, EHRs and HIE CHRISTINA BEACH THIELST, FACE
EXECUTIVE DIRECTOR, NORTHWEST REGIONAL TELEHEALTH CEN- ABSTRACT: From the American Recovery and Reinvestment Act (ARRA) and the newly passed healthcare reform legislationto emerging reimbursement models and shifting consumer health trends, a confluence of events are driving radicalchange in the nation's healthcare system and bringing about the convergence of telehealth, electronic health records(EHRs) and health information exchange (HIE).
That is the focus of "The Crossroads of Telehealth, Electronic Health Records & Health Information Exchange: Planning for Rural Communities," a new white paper from the Northwest Regional Telehealth Resource Center (NRTRC).
"Accelerating adoption and utilization of telehealth technologies, telemedicine in particular, will be critical to a successful stakeholder response to the disruptive changes that are underway in healthcare," said NRTRC ExecutiveDirector Christina B. Thielst, FACHE. "By leveraging telehealth networks and their existing infrastructures, RegionalExtension Centers, HIEs and other data-sharing initiatives will be better-positioned to fulfill their commitments to thehealthcare delivery system of the future – a system in which even the most rural and remote populations have timelyaccess to care and their health records." The white paper explores emerging trends and recent disruptors impacting the healthcare delivery system and examines the opportunities they present for the advancement of telecommunications-based health solutions and thebroadband infrastructure available through telehealth networks. It also takes an in-depth look at the various uses oftelehealth and the most common delivery models of telemedicine, as well as the role of the telehealth network andTelehealth Resource Centers (TRCs) in expanding the reach of these vital initiatives.
Finally, the white paper highlights the evolution of the REACH Montana Telehealth Network from facilitating tele- radiology at three remote sites into a consortium of healthcare providers at 18 sites linked by high-bandwidthtelecommunications in the north central region of Montana. REACH, which considers HIE to be a primary function, iscurrently working to leverage its existing T1 infrastructure to create the "railroad tracks" that will carry medical data andinformation within the region and beyond.
"This white paper is an excellent analysis of the intersection of telehealth and health information technology, and the opportunities and challenges this electronic technology will bring to rural America," said Terry J. Hill, Executive Director ofthe Rural Health Resource Center, the Duluth, Minn.-based national knowledge center for rural hospitals providingtechnical assistance, information, education and other resources to rural health care providers and their communities. Adds Thielst: "Crossroads is a valuable planning tool for any healthcare stakeholder, but it is especially important for rural communities wanting to address health information exchange. It is just one of many resources available through theNRTRC to help advance the involvement of teleheatlh networks in HIE initiatives and to help transform the telehealthinfrastructure into the ‘superhighway' across which remote and rural areas will finally be able to participate in thewidespread exchange of electronic health information." One of five TRCs in the nation, the NRTRC leverages the collective expertise of 33 telehealth networks across Alaska, Hawaii, Idaho, Montana, Oregon, Utah, Washington, Wyoming, and United States-affiliated Pacific Islands to shareinformation and resources which assist in the development of new telehealth programs. The NRTRC is focused on furthergrowth and new provider adoption of telehealth technologies to enhance delivery systems and reduce organizational andpatient costs.
World Hospitals and Health Services Vol. 46 No. 4 17
17-23 Thielst:28 7/1/11 09:37 Page 18 Management: ehealth Recent federal actions and several emerging trends are Figure 1: indicative of future change for healthcare and, morespecifically, telehealth. The convergence of the American Recovery and Reinvestment Act (ARRA) of 2009, FederalCommunications Commission (FCC) Broadband Plan and recentlypassed health reform legislation – the Patient Protection andAffordable Care Act and the Reconciliation Act of 2010 – has thepotential to radically disrupt the U.S. healthcare system.
Other potential disruptors include widespread attention to the cost-benefit analysis of care processes and treatment (outcomes-based medicine), reimbursement models favouring preventive careand bundled payments, as well as provider shortages, significantpayor technology investments and the emergence of the nextgeneration of mobile devices. Also at play are an aging population,the growing popularity of medical tourism and shifting consumer expectations of healthcare.
For example, telehealth networks provide the infrastructure that Telehealth, the delivery of health-related services and enables Internet access and drives HIE in areas where commercial information via telecommunications technologies, offers solutions broadband is lacking or cost-prohibitive. Correspondingly, health that can facilitate the outcomes needed to respond to these IT offers enabling components for remote care and provides changes. Currently, telehealth is most often utilized for education complimentary tools and systems, such as electronic health and administrative or operational purposes and less often to records (EHRs) and digital data/information sharing.
enable clinical encounters (telemedicine).
We are approaching the intersection of telehealth, EHRs and The reasons for slow adoption rates and underutilization of HIE. At this crossroad, we can expect to see this interdependence telemedicine are varied. Among the most significant is that the become more pronounced as more common ground is realized, benefits of its use most often accrue to others, rather than to the shared visions are established and opportunities for mutual provider or network of providers who assume the upfront and support and collaboration are identified. This will lead to ongoing costs. Also frequently cited are high equipment costs, converged paths, more efficient use of resources and the outdated regulations and reimbursement limitations. However, integration of health information and telehealth technologies.
when it comes to the financial impact of provider-to-providertelehealth technologies, research shows that, overall, the benefits Drivers of change of these systems far outweigh the costs to implement1.
The Office of the National Coordinator (ONC), FCC and federalreform legislation will be key drivers of radical change that Emerging telehealth opportunities ultimately leads to an alignment of telehealth and health IT. The There are opportunities on the horizon that will likely improve healthcare system and stakeholder (providers, payors, employers, telemedicine utilization rates. For example, ARRA allocates $19 suppliers, consumers, etc.) response to those changes will likely billion for adoption of health information technology (IT) systems result in an expansion of the role of telemedicine, remote and promotion of electronic health information exchange (HIE).
monitoring and other telehealth applications. For example, many The Health Information Technology for Economic Clinical Health stakeholders will be seeking technology tools that increase (HITECH) Act also creates funding opportunities to support the efficiencies, expand access to care and reduce costs – which are advancement of health IT.
some of the primary benefits of telemedicine.
Existing telehealth networks will also benefit from ARRA and In the case of ONC, which is charged with overseeing health IT HITECH. Participating in related incentive programs, capitalizing funding, the agency has been focused on facilitating EHR on funding opportunities and achieving meaningful use of health IT adoption and clarifying the definition of meaningful use. However, requires hospitals and physicians to have broadband Internet as evidenced by ONC's recent testimony at the Senate Special access. However, commercial T1 lines are prohibitively expensive Committee on Aging3, the agency's attention will soon shift to the in rural areas. In fact, it is estimated that 93 million residents and important role the telehealth infrastructure can play as an enabler 3,600 small physician offices in these regions don't have of interoperability and HIE, especially in rural and remote broadband access2.
Because they can deliver more affordable equivalent access, At its core, meaningful use4 is about improving health, this presents a very real opportunity for telehealth networks to transforming healthcare and: expand their value to members and the community by connecting  Improving quality, safety and efficiency.
rural and remote providers to the Internet across existing  Reducing health disparities.
infrastructures. It also presents new partnership opportunities that  Engaging patients and families in their healthcare.
will enable telehealth networks to expand those infrastructures  Improving care coordination.
and increase connection speeds.
 Improving population and public health.
Further, while telehealth and health IT initiatives have historically  Ensuring adequate privacy and security protections for operated on relatively separate tracks with limited crossover, their personal health information.
goals and activities are complimentary and truly synergistic. This isespecially true of the broader systems-based approach to delivery In order to reach Stage 1 and beyond, demonstrate meaningful 18 World Hospitals and Health Services Vol. 46 No. 4
17-23 Thielst:28 7/1/11 09:37 Page 19 Management: ehealth Medicare and Medicaid Timeline Figure 2: Medicare and Medicaid timeline  electronically generate and transmitpermissible prescriptions; Medicaid: hospitals that adopt after  send reminders to patients about HHS develop interoperability 2017 not eligible for incentives standards end of 2009 preventive/follow-up care in the patients' Medicaid Incentives begin Medicaid: non-hospital preferred format; and based physicians 1st yr cost Medicaid: non-hospital based no later than 2016 physicians no payments after standards complete 2021 or more than 5 yrs.
 provide patients with timely electronicaccess to their health information within 96hours of information being available to eligible 2009 2010 2011 2012 2013 2014 2015 2016 2017…. 2021
Medicare phase down incentive Medicare penalties begin Leveraging and expanding existing telehealth Medicare (FY2011) payments for physicians for non -meaningful users Incentives begin Oct. 2010 FY15 for hospitals network infrastructures will deliver to providers, calendar 2015 for physicians particularly those in remote and rural areas, the Medicare Incentives Medicare: Physicians who 1st payment Medicare Incentives affordable broadband connections they need to begin Jan 2011 for Is after 2014 receive no incentives non -hospital based physicians achieve meaningful use and avoid financial For its part, the FCC, through its National Sources: HIMSS http://www.himss.org/ASP/index.asp and AHIMA http://www.ahima.org/ Broadband Plan, established healthcare as anational priority and laid out its plan for driving use and ultimately avoid penalties which will be levied beginning in broader adoption of and innovation in e-care technologies. The October 2015, hospitals, physicians and other eligible providers plan addresses outdated regulations and establishes funding to will need both an EHR and broadband Internet access to: help providers purchase services and build out broadband  report ambulatory quality measures to Centers for Medicare networks in areas where connections are lacking or are insufficient and Medicaid Services (CMS) or the States; to support video consultations and EHRs.
 check insurance eligibility electronically from public and private The FCC has adopted a new, broader view that looks beyond the single network connectivity perspective and addresses  submit claims electronically to public and private payors; government decisions that influence the system in which private  provide patients with an electronic copy of their health individuals operate. The commission is looking at the whole information upon request; ecosystem of networks, applications, devices and individual  be capable of electronically exchanging key clinical information actions that drive value – not just the networks themselves.
with other providers and patient-authorized entities; In doing so, the FCC has recognized that broadband-enabled IT  submit electronic data to immunization registries; solutions can only be successful if critical issues are addressed –  electronically provide syndromic surveillance data and inadequate reimbursement, outdated regulations, insufficient data reportable lab results to public health agencies; capture and utilization, deficient connectivity, etc. – and existing barriers removed.
Figure 3: Broadband is mi ssi sing or to too expensive The FCC has also recognized the important role of mobile Estimated Locations Without Mass -Market Broadband Connections devices, remote monitoring and Percent of locations for each delivery setting interoperability. It estimates that Federally Funded Providers remote monitoring of vital signs and EHRs alone can generate savings of US$700 billion over the next 15-25 years. This includes US$200 billion from remote monitoring of congestive heart failure, All Locations with Rural Health C linics diabetes, chronic obstructivepulmonary disease and chronic wound or skin ulcers5 DS3 (45 Mbps) Urban Price Benchmarks Across the U.S.
and US$500 billion from Monthly service cost ($) implementation of EHRs.
Further, the FCC has stated its intention to remove barriers and transform the US healthcare system by:  Ensuring all providers have affordable access to sufficientbroadband connections Source: AMA, HRSA, IHS, Telegeography, USAC  Creating incentives for World Hospitals and Health Services Vol. 46 No. 4 19
17-23 Thielst:28 7/1/11 09:37 Page 20 Management: ehealth adoption of EHRs and remote monitoring Figure 4: Misaligned economic incentives technologies, including the expansion ofreimbursements where outcomes are proven Providers bear the implementation and training costs but do not Transforming the Rural Healthcare Program receive proportionate benefits by subsidizing both ongoing costs andnetwork deployment, as well as by Health IT Implementation & Training expanding the definition of eligible providers.
 Creating next-generation interoperability across clinical, research and administrative  Ensuring patients have access to and control over their health data Modernizing credentialing, privileging and regulatory requirements to increase access tocare and enable broader health IT adoption Better Health & Care Funding will be closely tied to meaningful use and other outcome measures to ensure that the FCC's support goes to providers who arefollowing the guidance of the Office of theNational Coordinator for Health InformationTechnology. It will require participating organizations and providers play in driving radical change that is expected to accelerate to meet outcomes-based performance measures and will track telehealth adoption. Approximately 61 percent of US adults look and publish progress.
online for health information9, 78 percent of Baby Boomers use the Finally, health reform legislation extends insurance coverage to web to gather health information and nearly 80 percent of an estimated 32 million people at a cost of $940 billion over the healthcare consumers are interested in accessing their medical next 10 years. Supporters expect it will lead to measureable records online10.
improvements in the delivery of and access to care, as well as to Clearly, consumers are turning to the Internet with rapidly patient outcomes and overall population health. But it will also increasing frequency too seek out information on symptoms, drive the need for more efficient care processes to accommodate diseases and conditions, and then discussing their findings with increased demands, particularly given current limitations in their physician and/or other healthcare providers. As such, they healthcare workforce resources and the push for lower costs.
are demanding broadband Internet access to help them do so Telemedicine, remote monitoring and other telehealth more efficiently. This will lead to better health choices and enable technologies may become attractive solutions for many providers, them to better manage their healthcare dollars and find the best payers, researchers and consumers as we begin responding to care at the lowest price – even if it means traveling to other these drivers of change and addressing such mandates as: communities, states or countries.
 improving care coordination; Consumers are also demanding more affordable healthcare, as  promoting solutions to address healthcare workforce needs; well as access to their personal health information on their home  researching comparative effectiveness of medical treatments; computers and/or mobile devices. A growing number also  increasing the burden of payors for managing the chronically welcomes the opportunity for remote monitoring of their medical conditions and is seeking ways to participate in online self-  levying penalties against hospitals for re-admissions; and diagnostic questionnaires. In fact, one study found that when rural  increasing payments to physicians who can provide high- home care patients had video visits exchanged for some of their in quality care compared with costs person visits, 98 percent reported satisfaction with the videosupplemented care and all found the equipment easy to use.11 Numerous studies demonstrate that telehealth can improve As a result of these shifts, we can expect to see more of a efficiency and lower costs. A remote monitoring study of elders in patient-physician partnership as healthcare consumers take a a senior living facility revealed a 36 percent reduction in billable more active role in their healthcare decisions. They may ultimately medical procedures, a 78 percent reduction in hospital days and translate into an increased demand for telehealth applications, a 68 percent reduction in the cost of care. Additionally, researchers including telemedicine, remote education and peer-support, and found that the efficiency of caregivers increased by more than 50 access to home monitoring technologies.
percent6. Further, a Veterans Hospital System CareCoordination/Home Health program realized a 20 percent The role of telehealth reduction in hospital admissions and a 25 percent reduction in bed Telehealth has demonstrated its effectiveness in educating clinical days with telehealth technologies7. Finally, of the 2.2 million staff and patients and facilitating administrative and operational patients transported between emergency departments each year, functions, as well as for clinical care purposes. These activities are real-time video consults could avoid 646,000 of these transports, typically undertaken using one of three primary modes: 1) store- resulting in total savings of $408 million8.
and-forward; 2) real-time monitoring; and 3) remote monitoring.
It is important not to overlook the role healthcare consumers Each mode offers the potential for significant, measurable 20 World Hospitals and Health Services Vol. 46 No. 4
17-23 Thielst:28 7/1/11 09:37 Page 21 Management: ehealth benefits. For example, one network has documented consumer outreach and services over the Internet.
improvements in access to and quality of care, as well asenhanced efficiency in the delivery of healthcare, decreased costs Key to the success of these models is the ability for providers to and reduced health disparities from using store-and-forward access the patient's medical record at the time of the remote technology alone12.
encounter – just as it is with in-person care. This is made possible At the higher end of the spectrum, the longitudinal EHR and by the establishment of telehealth networks, which offer a link telemedicine network facilitated by the Louisiana Rural Health between provider EHRs and the secure movement of health- Information Exchange (LARHIX) and featuring remote related information between doctors, hospitals and other providers consultations has shortened rural patients' wait times for access to when needed for care and treatment.
specialists. It also drove a 93% decrease in duplicative testing at When telehealth networks provide the broadband to healthcare facilities, they not only offer Internet access, but more importantly The primary benefits of telehealth are its ability to enable more create a secure network connecting providers so they can cost-effective use of patient and provider resources and to exchange information without going through the public Internet. By increase access to both routine and specialist care. Some of the taking this role, telehealth networks become responsible for most common/popular uses14 of telehealth include: network management and information security.
 A specialist participating in a remote consult with a family There are currently approximately 200 telehealth networks physician to assist with a diagnosis.
linking more than 2,500 institutions in the US16, all at varying  A family physician facilitating a consultation with a specialist by degrees of maturity. That is an impressive number considering that transmitting radiology images and/or video along with patient the telehealth pioneers of the 1990s had to build their networks data to a specialist for viewing.
from scratch. To support these pioneers and the advancement of  Patients and health professionals sharing audio, video and telemedicine, the Office for the Advancement of Telehealth in the remotely captured medical data to design or monitor treatment Office of Health Information Technology, Health Resources and plans, verify prescription refills or provide advice.
Services Administration17 began providing funding to support  Using devices to remotely collect and send data to a Telehealth Resource Centers (TRCs) through the Telehealth monitoring station for interpretation, such as telemetry devices Resource Center Grant Program.
that capture a specific vital sign (blood pressure, glucose, ECG Today, five TRCs18 are available to leverage existing knowledge, or weight), and to supplement the use of visiting nurses.
share information and resources, and assist with the development  Medical education and mentoring, such as the provision of of new telehealth programs. These invaluable resources also continuing medical education credits, special medical support emerging telehealth networks with readiness, technology education seminars for targeted groups, and/or interactive and equipment assessments, business model development and expert advice during a medical procedure.
program guidance. Other services typically include resources and  Utilization of the Internet by consumers to obtain specialized assistance with clinical protocols, training, reimbursement, health information or to access online discussion groups and legal/regulatory and strategic planning.
One TRC, the Northwest Regional Telehealth Resource Center (NRTRC), leverages the collective expertise of 33 telehealth Of the three primary modes of telehealth, the most underutilized networks in Alaska, Hawaii, Idaho, Montana, Oregon, Utah, application is telemedicine, which allows providers to remotely Washington, Wyoming and US-Affiliated Pacific Islands. It perform monitoring, diagnosis, triage, consultation and procedural collaborates with other TRCs and supporting organizations to care processes. It is highly effective, and technical advances are identify and design sustainable enterprise-wide solutions that creating new opportunities for providers to expand remote contribute to improved health and a more efficient healthcare services, such as the provision of ongoing chronic care The NRTRC supports physicians, hospitals, clinics and other The four most common delivery models15 for telemedicine are: providers as they strengthen the role and contributions of 1. Networked programs linking tertiary care hospitals/clinics with telehealth, including its ability to address interoperability with EHRs outlying clinics and community health centers in rural or and HIEs. It is poised to also assist Regional Extension Centers suburban areas through either hub-and-spoke or integrated (RECs), which are now being funded to support providers in the networked systems.
adoption of EHRs. The NRTRC facilitates collaboration and 2. Point-to-point connections using private networks that allow connections in an effort to eliminate gaps in service and will: hospitals/clinics to deliver services directly or outsource  Explore best practices of member networks that relate to specialty services to independent medical service providers. Or patient care and improved outcomes as they work to point-to-point connection between the health provider and simultaneously adopt EHRs and telehealth.
patient home (including residential care, nursing homes and/or  Provide technical support services to new and existing assisted living facilities) over single line phone-video systems members as they begin to: for interactive clinical consultations.
– Engage in EHRs (if they haven't done so already); 3. Direct patient-to-monitoring-center links, which allow patients – Engage in telehealth and incorporate it into their EHR; and/or to maintain more independent lifestyles and are most often – Participate in HIE opportunities to attain meaningful use and used for pacemaker, cardiac, pulmonary or fetal monitoring access incentives.
and related services  Educate stakeholders on the role of health IT and telehealth.
4. Web-based e-health patient services, which provide direct  Address barriers, including network security, ISP contractual World Hospitals and Health Services Vol. 46 No. 4 21
17-23 Thielst:28 7/1/11 09:37 Page 22 Management: ehealth issues and interoperability of telehealth and health IT.
 Assist participating providers as they plan for and manage the We can expect telemedicine and remote monitoring to play a adoption of remote monitoring technologies, including the re- significant role in the healthcare delivery system of the future.
design of clinical workflows; revision of protocols for Existing telehealth networks will prove to be an important resource processing data and information; changing job roles and for providers who want to enhance service offerings, improve responsibilities; and integrating interoperable medical devices.
efficiency with remote care applications and/or participate in HIE.
 Create a template for rolling together EHR, HIE and telehealth Their involvement in HIE initiatives will lead to the next generation so that the physician can see diagnostic images and the EHR of interoperability and a blended vision for both health IT and during the telemedicine encounter.
telehealth. It will also lead to a transformation of the telehealthinfrastructure into the highway for electronic health records and Case study: REACH Montana Telehealth Network information exchange for many rural and remote areas.
REACH (Realizing Education And Community Health) Montana TRCs like the NRTRC will leverage the depth of their resources Telehealth Network has evolved from facilitating tele-radiology at and work in conjunction with RECs, HIEs and other supporting three remote sites into a consortium of healthcare providers at 18 organizations to enhance the value telehealth programmes deliver sites linked by high-bandwidth telecommunications in the north to their individual initiatives. We recommend that telehealth central region of Montana. From its hub site at Benefis Health networks prepare now and get involved in the conversation to System in Great Falls, this telehealth network serves rural and ensure that the initiatives covering their community or region are frontier counties that are geographically large, remote and sparsely aware of the network's existence and capabilities.
populated, providing both distance learning and medical services.
Telehealth leaders have unique insight and are ideally positioned Since REACH's beginning in 1995, the federal government has to influence the development of HIEs, minimize the risk of helped fund the build-out of its T1 infrastructure and the current duplicative efforts and resources and increase the likelihood of move toward fiber to create the "railroad tracks" that will carry success as we improve the delivery of healthcare and access to medical data and information within the region and beyond.
the patient's health record.
Because of its overlaid relationship with the Northcentral Montana As we move away from a fee-for-service model and put more Healthcare Alliance, REACH has been part of the EHR and HIE value (and reimbursement) into health promotion and prevention conversation since the Alliance began developing its health IT we can expect to see new business cases supporting telehealth projects. It is using its hub-and-spoke network and leveraging its applications. We also expect to see more and more small collaborative provider relationships to offer its existing hospitals and providers applying the telehealth technologies to infrastructure as a solution to integrate health IT and prepare the help them care for their patients and compete for those willing to region for HIE to bring the patient record to providers at the time travel for the best care at the best price. J of the telemedicine encounter.
REACH views HIE as a primary function of the network. Its leaders have long believed in the need to be collaborative, if not The Telehealth Resource Centers are supported through the integrated, with the health IT conversation. As the conversation Telehealth Resource Center Grant Program administered by the has moved toward implementing EHRs and establishing a health Office for the Advancement of Telehealth in the Office of Health information exchange, REACH has relied on its synergistic Information Technology, Health Resources and Services relationships to position the infrastructure (the railroad tracks) to Administration. This white paper has been made possible by grant carry health information and its organizational structure to facilitate number G22TH07767 from the Office for the Advancement of the business and governance processes. The first HIE project Telehealth: Health Resources Service Administration/DHHS involves implementing an EHR at one of the small rural hospitals and connecting it to Benefis Health System.
REACH manages the relationships, network of T1 lines and Christina Beach Thielst, FACHE is a former hospital administrator deployment of hardware and software between participating sites who has experienced the evolution of the healthcare delivery and relies upon the Benefis IT Department to support the network system for the past 30 years. She also has expertise establishing technically (servers, bridges, technology, etc). As health IT governance and administrative structures for health information matures, it envisions an expansion of the network to other rural exchanges and most recently lead activities of the Northwest hospitals and providers, as well as to support medical homes with Regional Telehealth Resource Center to promote the adoption of remote monitoring.
telehealth and related technologies to enhance delivery systems In addition to demonstrating the potential of a telehealth and reduce organizational and patient costs. network, REACH is an example of the role TRCs play in expanding Her innovative work has been published in leading healthcare these vital entities. REACH has benefited from the resources magazines and journals, and she served as editor for the HIMSS offered by the NRTRC, including utilizing the evaluation tool for Guide to Establishing a Regional Health Information Organization. new site selection and the reimbursement pocket guide. It has Her latest book, Social Media: Connect, Communicate, also relied upon the NRTRC to help establish connections beyond Collaborate, was published in May. its immediate service area to foster a growing network of support.
Christina received a Masters Degree in Health Administration As REACH proceeds down the path of HIE, it will rely on the from Tulane University, School of Public Health and Tropical NRTRC to scan the horizon, distill information, share innovative Medicine and is a member of the American College of Healthcare resources and make the new connections that will help the Executives, Health Information and Management Systems Society network prosper in the new healthcare delivery system.
and the American Telemedicine Association. 22 World Hospitals and Health Services Vol. 46 No. 4
17-23 Thielst:28 7/1/11 09:37 Page 23 Management: ehealth 1. Caitlin Cusack, et al, The Value of Provider-to-Provider Telehealth Technologies, Center for 2. Connecting America: The National Broadband Plan, Federal Communications Commission, 3. Senate Special Committee on Aging, Agin in Place: The National Broadband Plan and Bringing Health Care Technology Home, April 2010. http://aging.senate.gov/ 4. ONC Meaningful Use 5. Robert E. Litan, Vital Signs via Broadband: Remote Health Monitoring Transmits Savings, 6. Susan L. Dimmick, Carole Mustaleski, Samuel G. Burgiss & Teresa Welsh, A Case Study of Benefits & Potential Savings in Rural Home Telemedicine, Home Health Nurse. 2000Feb;18(2):124-35.
7. Darkins A, et al. Care Coordination/Home Telehealth: The Systematic Implementation of Health Informatics, Home Telehealth, and Disease Management to Support the Care ofVeteran Patients with Chronic Conditions, Telemedicine and e-Health. 2008, 14(10): 1118-1126.
8. Caitlin Cusack, et al, The Value of Provider-to-Provider Telehealth Technologies, Center for 9. Susannah Fox, Sydney Jones, The Social Life of Health Information, PEW Research Center, 10. Kemper, D.W. and M. Mettler. 2008. E-Coaching for Boomer Health, 11. Susan L. Dimmick, Carole Mustaleski, Samuel G. Burgiss & Teresa Welsh, A Case Study of Benefits & Potential Savings in Rural Home Telemedicine, Home Health Nurse. 2000Feb;18(2):124-35.
12. A. Stewart Ferguson, et al, Impact of Store-And-Forward Telehealth in Alaska: A Seven Year Retrospective, AFHCAN/Alaska Native Tribal Health Consortium, 2008-09.
13. Health Information Exchange: Patient Data on the Move, CMIO Magazine, Sept/Oct 2009 14. Telemedicine, Telehealth, and Health Information Technology, ATA Issue Paper, May 2006.
15. Telemedicine, Telehealth, and Health Information Technology, ATA Issue Paper, May 200616. American Telemedicine Association World Hospitals and Health Services Vol. 46 No. 4 23
24-26 Pluguru:28 7/1/11 10:26 Page 24 Management: hospital design Institutional transfer from the Europeandesign practices to Ukraine andMoldova: the case of hospital design RODICA PLUGARU, PhD
INSTITUTE OF POLITICAL STUDIES, GROUPE-6 ARCHITECTURE FIRM, GRENOBLE, FRANCE ABSTRACT: This article explores the development of post-soviet hospital design through the analysis of recent modernisations inMoldova and Ukraine. It consists of two parts. First, an introduction of the definition of hospital design as well as its maincharacteristics during the Soviet period.
Secondly, a presentation of two hospital modernisations in Ukraine and Moldova. In a comparative perspective, the paper presents the actors involved, the difficulties in modernising the hospital regarding the inherited rules as well as the solutionsadvanced in order to implement a change.
An introduction to the hospital design in Moldova and Ukraine will allow an in-depth study of the involvement of international actors in the post-communist transformations.
My research concerns the institutional transfer from and research, the hospital is a major element of the health care European Union actors to Ukraine and Moldova. Part of system (Rechel et al., 2009b). Over the last decades, the hospital the studies on post-soviet states development, the thesis acquired an economical and societal role, by employing significant is focused on the transformation of institutions and the personnel and using the most advanced medical technologies1.
participation of foreign actors into the observed processi. In this These elements stress the fact that the design of a hospital is not article, I present a brief introduction to the post-soviet hospital only a technical concern – of using the most innovative design and design through the analysis of two hospital modernisations. The construction methods, but also a political one – of providing the countries of my analysis are Moldova and Ukraine, due to their adapted care to the health needs of the population (Rechel et al., geopolitical strategic position: at the crossroads of Europe and 2009a). Despite this, as some commentators deplore, the political Asia, at the centre of European and Russian influences (Serebrian, science has paid little attention to the hospital as institution 2004). Rather different in terms of territory, demography and (McKee and Healy, 2000).
economic indicators, both states experienced over fifty years of Defining the hospital design is not a simple task. Several similar background. In line with historical approach of the new explanations can be found in the literature of architecture and institutionalism in political science, I argue that Ukraine and construction which describe the process of design for the Moldova present similar characteristics of hospital design following specialists of the field. It can be noticed that the hospital design Soviet Union's collapse.
involves a large amount of information from different areas: A complementary hypothesis stresses the involvement of medicine, architecture, engineering, urbanism etc. The 665 pages international companies in the design of new hospitals in these of the "Planning the hospital space" of Maurice le Mandat, called states. This paper is structured in two parts. First, I expose the more usually "The Bible" by the French architects, give an idea of hospital design characteristics of Ukraine and Moldova during the the knowledge to at least broadly understand while designing a Soviet Union. Second, I present two hospital modernisations hospital (Le Mandat, 1989).
following the independence. The comparative presentation of the In this paper, I define the hospital design as a process according two projects will allow verifying the announced hypotheses, while to which a large amount of actors interacts upon a significant enlarging the existing literature on post-soviet transformationsii.
corpus of regulations in order to deliver appropriate designsolutions. More precisely, I will focus on the design of tertiary care Part I: hospital design characteristicsIn this first part of the paper, I present the definition of the hospital i. Since July 2008, I realize my PhD in political science within the PACTE laboratory and the design, while introducing several of its characteristics during the French design practice Groupe-6, in Grenoble, France. According to the grant CIFRE, of which I Soviet Union.
benefit, a research unit, a private structure and a doctoral student explore a research subjectof common interest.
ii. I present these elements following the observation of the design of a Ukrainian hospital by the 1. The hospital design as a process French company Groupe-6, combined with a three months study visit in Moldova and Ukraine Giving its role of diagnostic and treatment, but also of teaching 24 World Hospitals and Health Services Vol. 46 No. 4
24-26 Pluguru:28 7/1/11 10:26 Page 25 Management: hospital design hospitals, which deliver high-complex services of diagnostic and comparative description between the two examples will be used in order to reveal the similarities and the differences of thehospital design. The scheme I suggest contains the involved 2. Characteristics of a design process Actors, the Obstacles in implementing new design preferences Put bluntly, the realisation of a building involves three main stages: as well as the Solutions adopted in order to move away from the  The programming: determines the general and detailed inherited paths.
characteristics of organization, functioning, areas, equipments,personnel staff and cost of the building.
The actors  The design: implies the making of the plans for the future The idea of the Children Hospital of the Future in Kiev, Ukraine was building. A design team composed of architects, engineers, launched by the Foundation Ukraine 3000 when Kateryna programmists and economist are working together Youchschenko, the first lady and Chairman of the organization, in order to prepare the drawings for the construction.
noted the absence of medical institution for cancer diseases in the  The construction: according to the previous phases and the country6. The idea gained political support and was launched as a received plans, construction firms work for the realisation "in project in 2006. The Administrative Department of the Presidency flesh" of the project.
(ADP) of Ukraine prepared the legal framework of the initiative7.
In Republic of Moldova, the idea of restructuring the Republican The process of design during the soviet period was Clinical Hospital was presented within the reform of the hospital characterized by "typical projects" (called in Russian language sector8. During the implementation of a main reform project, the typovyie proekti). Specialized design institutes issued "typical Ministry of Health edited a report presenting the deplorable projects" for different buildings: hospital, schools, laboratories etc.
situation of hospitals. Following this state of the art, the Ministry The "typical project" was supposed to contain the best practices launched in 2007 the idea of creating 4 Centres of Performance – for a specific object. This sort of soviet "benchmarking" aimed to 4 Republican hospitals in the country. The Republican Clinical control the public expenditure on design and construction. Also, it institution of Chisinau, being the most important health facility, was partly explains why the buildings similarity all over the USSR placed on the top of the list.
Both Moldova and Ukraine called for international experience in Following the independence, the stages of building construction the field of hospital design following independence. International did not really change in Moldova and Ukraine. Nevertheless, the competitions selected foreign design firms. The French-British "typical projects" disappeared, as the centralized soviet model consortium bdpgroupe6 was chosen for the CHF in Kiev, while the German practice Top-Konsult was named for the feasibility studyof the RCH in Chisinau. These international companies made 3. The hospital design regulations partnerships with local architecture firms: Budova Centre-1 in The hospital design is a process largely framed by State Ukraine and Dolmen firm in Moldova. Their role was to help authorities. As Maurice Le Mandat puts it "the Department of implementing the foreign design solutions into the national specific Health in the United States produces about 600 regulations per year (…) while in France, there are about 450 texts to know fordesigning a hospital building". In other words, the hospital design The obstacles regulations allow States to control and supervise the construction The main difficulty of international actors involved in hospital of health care institutions, which represent after all, master pieces modernisations in Ukraine and Moldova was to implement their of their national health care policies.
ideas of developing the medical institution. During the Soviet During the soviet times, both Ukraine and Moldova had a unique Union, architects and engineers strictly applied the "rule book" and corpus of regulations that applied to the design of any building.
thus had little space left for their creative ideas. In Western Called SNIP ("building norms and regulations"), they applied to countries, the techniques of designing a hospital were related to a every construction on its territory. Additionally, there were GOST mutual exchange of practices and ideas all over the world9. These ("national standard of USSR") which indicated the required differences in designing the hospital as medical institution were at conditions for construction materials. State control authorities the core of the debates between international and national actors.
checked each design project upon the soviet SNIP and GOST Very soon after winning the international design competition for before allowing the construction of a building.
the CHF in Kiev, the consortium bdpgroupe6 understood that they In 1991, Ukraine and Moldova inherited of the soviet significant will not be able to put in practice their model of hospital if they had framework of rules for the hospital design. The majority of to comply with Ukrainian regulations. In the case of Moldova, it documents are kept in their soviet form until today. In Moldova, the can not be said that Top-Konsult need to go against the national norms are still essentially in Russian, while the official language regulations while preparing the feasibility study10. In the same time, after independence is Romanian3. Ukraine inherited of all the soviet this does not imply that they had no obstacles in introducing their norms as Moldova, but rewritten them in Ukrainian and called ideas in the Moldavian healthcare system11.
The solutions Part II: hospital modernisations in Ukraine and Moldova Facing difficulties in adopting the design solutions for the Kiev In the next section, I present several elements on two case CHF, the Foundation Ukraine 3000 obtained the Experimental studies: the Children Hospital of the Future (CHF) in Ukraine and status for the hospital project. This option represented an "opened the Republican Clinical Hospital (RCH) in Moldova5. A window" for the international design companies. As their World Hospitals and Health Services Vol. 46 No. 4 25
24-26 Pluguru:28 7/1/11 10:26 Page 26 Management: hospital design modifying the old hospital design rules. The fact that the inheritedprescriptions are more and more challenged, despite their official If in Ukraine it can be observed character, defends the assumption of a gradual transformation that a mechanism was found in following the independence of both states. J order to integrate the foreignideas into the hospital design, in Rodica Plugaru has a Master Degree in European Governance from Moldova it is not exactly the case the Institute of Political Studies of Grenoble, and a PhD in politicalscience. Since July 2008, she works at the PACTE laboratory and the French architecture firm Groupe-6, in Grenoble, France. representatives explained, it was considered an official opportunity to integrate the foreign solutions into designing a hospital in Le Mandat, M. (1989) Prévoir l'espace hospitalier. in Berger-Levrault (ed) Paris.
Ukraine. In the same time, local representatives stressed the McKee, M. and Healy, J. (2000) The role of the hospital in a changing environment. Bulletin importance of national features during the project implementation.
of the World Health Organization. 78 ed., pp. 803-10.
The Experimental status need thus to be considered as an Rechel, B., Wright, S., Edwards, N., Dowdeswell, B. and McKee, M. (2009a) Introduction:hospitals within a changing context. Observatory Studies Series N°16. Copenhagen: opportunity for the international actors to express more easily their WHO Regional Office for Europe.
ideas, rather than an immediate approval of the latter.
Rechel, B., Wright, S. and McKee, M. (2009b) Translating hospital services into capital asset If in Ukraine it can be observed that a mechanism was found in solutions. Observatory Studies Series N°16. Copenhagen: WHO Regional Office forEurope, pp. 206-27.
order to integrate the foreign ideas into the hospital design, in Serebrian, O. (2004) Politica si geopolitica, Chisinau, Cartier.
Moldova it is not exactly the case. After analysing the experienceof RCH as well as more generally the design of a private hospital End Notes1. On the roles of the hospital as a medical institution, see McKee, M. and Healy, J. (2000) The in Chisinau, I did not identify any institutional procedure for role of the hospital in a changing environment. Bulletin of the World Health Organisation. 78 breaking with the existing design regulations. The only possibility ed., pp. 803-10.
left for international design companies is to convince the State 2. There are several types of hospitals. They can be classified by the level of care provided: primary, secondary and tertiary. The primary care concerns "the services of sanitary organs that their ideas are more advanced than the old rule book education, prevention and first emergency" oriented to the population of immediate proximity. The secondary care concern "more specialised fields where patients are orientedfrom the primary care services". Tertiary care are the most specialised type of medicalservices (Le Mandat, M. (1989) Prévoir l'espace hospitalier. in Berger-Levrault (ed) Paris.).
3. In the Constitution of Republic of Moldova, the name of the official language is Moldavian.
This paper presented hospital design characteristics in Ukraine The latter is identical to Romanian and there is no scientific demonstrated difference and Moldova through the observation of two case studies. I between the two. Nevertheless, the language definition is used for political questions, as foravoiding per example a closer identification of Republic of Moldova with the neighbour state adopted a definition of hospital design in line with the institutional approaches in political science. According to it, the hospital design 4. Interview with Volodimir Pidgirniak, Director, Budova Centre-1, May 2010, Kiev, Ukraine.
can be analysed as a complex process of establishing the outline 5. The information is issued from my participation and observation within the design practice Groupe-6 in France. The hospital design project in Ukraine, which the firm realises, started of a hospital upon a specific corpus of regulations. The content of in August 2007 and finalised in May 2010.
this definition – the actors, the rules and the scheme of the 6. In Ukraine, there is no possibility nowadays to realise complex surgical operations due to process can differ from one country to another as well as from one the lack of necessary medical technologies and equipments (i.e. bone-marrow transplantfrom other donors than relatives).
period of time to another. Given the fact that Moldova and Ukraine 7. The presidential decree N° 1694/2005 on 6th December 2005 specified the creation of the had common hospital design trends during the Soviet Union, this All Ukrainian Mother and Children Health Centre. The Cabinet of Ministers approved the paper aimed to observe if they adopted similar or different adoption of the presidential decree by the resolution N°72 on 25th of May 2006.
8. Several legislative acts put the basis of the hospital sector development: the National solutions following their independence.
Strategy of development for the years 2008-2011, adopted by the Law N°295-XVI of I assume that there is a similar feature of hospital design in 21.12.2007, the Action Plan for implementing the National Strategy of development, Ukraine and in Moldova as international design companies are approved by Government decree N°191 of 25.02.08 and the Development Strategy of thehealth care system for the period 2008-2017, approved by Government decree N°1471 of present in both states during the post-soviet period. As the two case studies suggest, the post-soviet hospital design is the 9. Interview with Conor Ellis, Health Director, EC Harris, Montpellier, France, 21st of July 2010.
outcome of complex debates between foreign and national 10. The main reason is that there is no check out upon the design norms, as the solutions presented are at their very initial stage.
representatives. Confirmed by numerous interviews during my 11. For example, the reorganisation of operating theatres was intensively debated by the stay in Ukraine and Moldova, none of these elements were present Board of the Hospital and Top-Konsult. The designers suggested reducing the number of during the Soviet Union regime.
theatres, from 27 nowadays to 7. In the opinion of foreign specialists, the operating theatreshad to work 24 hours a day in order to optimize their cost. This solution was found At the same time, Ukraine and Moldova adopted different inconvenient by the Moldavian part.
solutions for the introduction of foreign design elements. In 12. In this context, each time Top-Konsult suggested a new concept of organising the future Ukraine, the Experimental status, a procedure available since hospital of Chisinau, it need to convince the Ministry of Health representatives, the Board ofthe Hospital as well as other concerned national authorities. There was no regularity on the 2007, allows some projects to adopt international experience. In acceptance or the refusal of authorities concerning the suggested schemes.
Moldova, the absence of such a procedure entailed the respect ofnational regulations. The foreign designers had yet the possibilityto directly convince the national administrations to approve theirsolutions. Consequently, the mechanisms adopted in order totransform the medical institutions in Moldova and Ukraine, eitherdifferent, intended to respond to the common problem of 26 World Hospitals and Health Services Vol. 46 No. 4
27-29 PonceDeLeon:28 7/1/11 10:27 Page 27 Management: quality and culture Quality and culture of health SARA ALICIA PONCE DE LEÓN MUÑOZ
NURSE AND MIDWIFE, FOUNDING DIRECTOR OF THE SCHOOL OF NURSING AND OBSTETRICS OF THE NATIONAL POLYTECHNIC INSTITUTE ABSTRACT: Healthcare has as its framework, a culture of disease which primarily comes from biology, and is meant to: diagnose,cure, prevent and rehabilitate. Health problems show that the efforts and great advances in medicine are not enough. To improveactions within this same culture does not seem effective. Changes are needed to create a culture of health. The characteristics ofnurses' work and its potential, open opportunities to improve the quality of care, having LIFE at the centre.
Ageneral reflection on living conditions and health shows the society's quality of life.
lack of equity among populations. Any work on quality With this conviction, we have started in Mexico a project in must address this problem. It is evident there are great continuous education that we believe can give nurses' work the advances and efforts to improve treatment, prevention and power to improve the population's living conditions.
rehabilitation, but results in people's quality of life and the serioushealth problems which are present, manifest that these are not Quality and culture of disease enough, nor do they achieve the level of efficiency that is The great scientific and technological advances are amazing; consistent with the needs.
these have had a great impact on healing and on the prevention of The great majority of people live in conditions of poverty which disease, as well as on the rehabilitation of patients, and have determine serious deficiencies in fundamental aspects such as greatly increased life expectancy.
nutrition, education and the lack of healthy lifestyles. In this However, any reflection on the serious physical and situation, the unavoidable consequence, if the causes are not psychological health problems that exist, and the shortcomings addressed, is the creation of a state of vulnerability where multiple which make it impossible to have a harmonious family life, at the factors are involved with need to be solved.
national and international levels, as well as with the environment, Providing care mainly for people who are already sick and show the great discrepancy existing between society's health treating the damage without considering the primary causes, the needs and the system's response to satisfy them.
involved factors and the context in which they are produced, leads Actions are partial, although there is insistence on providing us to question the quality of care.
integral care. The predominant actions are in curing and the The predominant orientation in healthcare has disease as its prevention of physical diseases, but in spite of all resources and axis. Those who provide care have also been trained with this efforts invested, the old physical problems still exist, to which are focus that emphasizes the cure. One of the consequences of this added those which appeared more recently, the psychological and is the medicalization of problems.
social ones. All pose a threat to the quality of life and to life itself.
Health services and their personnel, governments, users and To give some examples, we can mention problems such as: the general society are conditioned by the culture of disease. Even  The ancestral diarrhea, which is the cause of 50% of deaths.
nurses' work, in spite of their training in public health, leads them  One out of twelve children dies before age 5, due to to perform their professional duties according to policies and foreseeable causes.
actions centered on this culture.
 Malnutrition leads to an infinite number of problems; Health is much more than a biological phenomenon; quality care specifically, to infections and a difficulty in the healing of requires changes based on a perspective that will consider human wounds, which in turn extend hospital stays.
beings in all their breadth and the training of health personnel with  Iron deficiency causes 100 thousand deaths annually, of a life-affirming vision, carrying out their work in multidisciplinary mothers during childbirth.
 Depression, not wholly quantified, has an impact on all Generally, improvements in care are oriented towards doing spheres. It is very significant that of every three persons with better what is already being done, within the guidelines of a culture depression, two are women.
of disease. Nurses, with the potential of their training and having  Family violence has increased, according to UNICEF reports.
acquired new skills in their work with individuals, families andcommunities, can provide healthcare that modifies this culture, Poverty is manifested as well as educational poverty, which strengthens healthy lifestyles and contributes to improving limits people's ability to be and to do, their work opportunities and World Hospitals and Health Services Vol. 46 No. 4 27
27-29 PonceDeLeon:28 7/1/11 10:27 Page 28 Management: quality and culture access to basic and general services for their health.
human potential, the influence of impoverishment, humiliation, The analysis of health problems and healthcare may help us despair, the problems pertaining to the medicalization of systems understand and value the level of quality of care. Is the system and their need to respond to "people's expectations". To care for responding in a reactive way to the symptoms of problems? To people according to their needs and not to their ability to pay.
what extent are the fundamental causes not being addressed? It Although these ideas are valuable and go beyond the traditional is clear that the health system cannot solve all the socioeconomic viewpoints, there is still uncertainty when actions are focused on system, but this does not mean that it cannot work in disease, on care for damage with a biological emphasis, without multidisciplinary teams and establish interaction with the other considering the social context nor the primary causes that are sectors in the system.
involved. It is evident that it is not easy to go from a culture of Malnutrition, for example, from which multiple problems arise – disease to one of health, centred on life and on the promotion of physical and educational problems, as well as those related to actions to promote a biophilic orientation.
productivity and, in general, to all actions and relationships of In this culture, health is perceived as a social phenomenon and those who have this condition – clearly shows the lack of quality in not only a biological one. Healthy lifestyles and self-care for health care when only the physical aspects are cared for.
are favoured; human potential is promoted to improve the life The same can be said for violence, which goes beyond conditions of individuals and groups, so that people will not need generations and affects family life, in all social spheres of each to be hospitalized nor be users of health services, for causes that country and between countries. It is the common denominator may be avoided. There is an orientation towards development and affecting health at all levels, from the family to the socioeconomic the exercise of human rights, as well as promotion of harmonious system. An example of violence is the concentration of wealth.
relationships in families, in their social context and their interaction For women it is evident there is a lack of equity, above all in the with the environment.
inequality of opportunities; it reflects on nutrition, on the The affirmation of life as an axis requires the development of acknowledgment of capabilities and values, on education, physical, psychological and social strengths, the promotion of a employment and on citizen and political participation. It is not culture of human rights and providing of care from the perspective possible to think of healthy lifestyles if in daily life violence is of causes. In this relationship, which is life driven, all participants manifested in diverse forms, including with physical aggression.
learn in a permanent process of development.
Faced with this situation, the system provides care for the physical The vision that is centered on human nature and on seeing damage, the wounds, but does not address the causes that lead health as a condition where multiple causes and factors are to this harm.
involved, shows that there cannot be care with quality if we The health system provides care to individuals without relating continue with the traditional health team, or with a unidisciplinary their disease to the deficiencies that are implicit in the disease. The leadership where the treatment of diseases is dominant. Quality perspective of healthcare does not consider the social context nor care, require multidisciplinary work, and leadership that responds the socioeconomic factors which have an effect on health. This to the needs and their causes.
model of care requires an expensive advanced technology, whichnot only affects the economy but also productivity, human relations Quality and strategies and leads to suffering.
To achieve a culture of health, with a life-affirming orientation, may Policies and decision-making come from a perspective of be seen as a dream. The great advances start like this and would disease, above all of physical disease, in order to cure it. The remain in the imagination if there were no long-term vision. For a system acts mainly when people are already sick and conditions culture of health, it is necessary to work in all social spheres.
the population to seek for care in order to get cured, thus Commitment is needed, and all personnel require updating for the promoting a CULTURE OF DISEASE.
creation and exercise of this culture to exert continuous effort inorder to carry out quality work within a new life-affirming Quality and culture of health If we aspire to elevate the population's level of health, will it be We know that in healthcare it is important that all have an enough to do better what we are already doing? If we have efficient participation. As in any other change, everyone needs to disease as a focus, will we be responding to the health needs of acquire capabilities that will allow them to have quality in their families and communities? Will people's quality of life be performance, in order to achieve the common objectives, contributing their work according to the functions assigned to Reports on meetings, analyses and studies show there is an interest in improving health systems and evaluating their efficacy A fundamental effort is in the development of nurses' and efficiency. The Director of the World Health Organization capabilities. These professional personnel have the greatest suggests performing a scientific test to evaluate them, improve the training in public health and their work conditions, characterized quality of data and disseminate them among the member by direct and continuous contact with the population, every day of the year, give them the opportunity to promote healthy lifestyles We may also recognize and understand the role that health and the strengths of healthy and sick individuals, of their families plays in development and well-being. The development of a and in the diverse communities.
country is based on human development, which means the The objective is to make life the centre of our work and create a citizen's ability to "fulfill his/her capabilities" and take full advantage model that is not subordinated to the curing of diseases but to of opportunities.
human development, in order to be applied to any field of human The above shows another perspective on health. It considers existence, with people and in groups. Nurses are the key 28 World Hospitals and Health Services Vol. 46 No. 4
27-29 PonceDeLeon:28 7/1/11 10:27 Page 29 Management: quality and culture professionals to contribute a social force for the development of a health culture.
Giroux, Henry. Teoría y Resistencia en la educación. Ed.Siglo XX1. México, 1992.
Participation of authorities requires joint planning, oriented Leddy, Susan y Pepper, J. Mae. Bases conceptuales de la enfermería profesional. Ed. J.B.
towards the task of achieving change and providing support to Lippincott Company. Filadelfia. Organización Panamericana de la Salud. 1ª Edición en make life a valuable event that is worth being lived.
Español. 1989.
Morán Victoria y Mendoza Alba Lily. Modelos de enfermería. Ed. Trillas. México, D.F., 1993.
With this perspective, we have begun in Mexico, at the National Organización Panamericana de la Salud, Guía para la gestión de la atención primaria de salud, College of Nurses (Colegio Nacional de Enfermeras), a project of Professional Certification. This program is carried out through Rogers, Carl R. Grupos de encuentro. Ed. Amorrotu Editores. Buenos Aires. 2004Senge, Peter M. La quinta disciplina. Cómo Impulsar el Aprendizaje en la Organización seminars where learning units are taught with functions and Inteligente. Ed. Granica México. S.A. de C.V. Impreso en México. 1998.
activities oriented towards a health culture. One of them is OMS. Resolución del Consejo Ejecutivo, 107ª Reunión. Evaluación del Desempeño de los leadership and its application in healthcare and the dissemination Sistemas de Salud, 19 de enero ,2001.
OMS. Informe sobre la salud en el mundo, junio, 2000. Mejorar el Desempeño de los Sistemas of this culture.
de Salud. Grupo de Expertos, Cuarto Consenso. Comentarios al informe de la OMS sobre LaSalud en el Mundo en el Año 2000.
OMS. 2005. Ediciones de la OMS. Estudio Multipaís de la OMS. Salud de la Mujer y Violencia Doméstica Contra la Mujer. ISBN 92435935 IX.
The Health System is determined by the model that has disease at its centre. Healthcare consists of curing, preventingdisease and rehabilitating. Work is focused on the repairing ofdamage.
 The disease-centred focus induce people to requesting services when they are already sick or when they requireprevention for some kind of disease. This orientation createsand re-creates a Culture of Disease.
 In the discourse on health policies, the need is acknowledged to improve the quality of services in order to improve quality oflife.
 The health problems and life conditions of most of the population show the need to make changes that betterrespond to the needs of a healthy life and not only to improveon what is already being done. It is not efficient or efficaciousto do more of the same, which has already shown thepersistence of a problematic situation with respect to healththat does not achieve a life with dignity.
 Change requires a perspective that is not limited to repairing the damage or to preventing some diseases.
 We need to create and promote a Culture of Health oriented towards: helping people recognize and use their power toachieve a healthy life with dignity; promoting the developmentof their potential and the exercise of their human rights;favoring the full realization of their existence, in harmony withothers and with the environment.
 In a culture of health, the process of care is based on the affirmation of life, through an interaction where we all learn.
 The potential, training and characteristics of nurses and their work, are conditions that make it possible for them to createand develop a culture of health.
 Their performance is with healthy or sick people, at the government levels, with the training of personnel, in thedevelopment of health policies and, in general, with all thepopulation. J Sara Alicia Ponce de León Muñoz is a nurse and midwife withpostgraduate courses in gender studies and a Founding Director ofthe School of Nursing and Obstetrics of the National PolytechnicInstitute. Currently she is an academic supervisor of highereducation in the same University. She has been actively participatingin the Colegio Nacional de Enfermeras from which shewas thepresident. She is now a member of the honour committee and theDirector of the professional certification program. World Hospitals and Health Services Vol. 46 No. 4 29
30-33 Blay:28 7/1/11 10:33 Page 30 Management: hospital marketing Hospital marketing: characterization of marketing actions in private hospitals in the city of São Paulo – Brazil EDUARDO BLAY LEIDERMAN MA, MBA,
DR PAOLA ZUCCHI, PhD
RESEARCHER, CENTRE FOR HEALTH ECONOMICS, CPES DEPUTY DIRECTOR, CENTER FOR HEALTH ECONOMICS PAULISTA JORGE LUIS PADOVAN
RESEARCHER OF CENTER FOR HEALTH ECONOMICS PAULISTA – CPES ABSTRACT: Objective: Characterize the marketing actions in private hospitals in the city of São Paulo, the organizational structure ofthe marketing area, the target public of marketing actions and the media used. Methods: Exploratory cross-sectional study, carried outby a survey made with hospital administrators. Results: The hospitals studied were clearly divided in two groups whose differentialsare statistically significant: 1. good infrastructure and equipment, with a well-defined investment policy in marketing; 2. worseinfrastructure and less equipment, with lower proportional investment in marketing. Conclusions: 1. The actions most used are theevaluation of patients/caregivers satisfaction, web site and dissemination of the hospital services. 2. The hospital administratorsattribute a level of significant importance to the application of hospital marketing concepts. 3. There is a marketing structure in mostof the hospitals studied. 4. The hospitals consider as extremely or very important publics: patients and relatives, doctors,collaborators, health plans and community. 5. The media most used are the most simple and of lower cost. 6. There is a statisticallysignificant correlation between the higher investment in marketing and the best infrastructure. 7. The studied hospitals apply theconcept of marketing in a restricted way.
The implementation of marketing concepts arrived belatedly hospitals in the city of São Paulo.
to the health area, at the end of the 1970s. Formally, healthservices marketing was recognized in 1977, the year in Secondary objectives which the American Hospital Association, first promoted a 2. Characterize the private hospitals in the city of São Paulo that discussion about marketing. In that year, it was also published the perform marketing actions, under the following aspects: first book on health services marketing in the United States. It was 2.1 Level of importance that hospital administrators attribute to at that same time – end of 70s, that American hospitals started the implementation of hospital marketing concepts.
organizing and structuring themselves in terms of marketing 2.2 Organizational structure of the marketing area. functions (Loures 2003). 2.3 Marketing actions performed.
Marketing is still seen with some skepticism by some 2.4 Target public of the marketing actions performed.
administrators of the health area, who imagine that it is necessary 2.5 Media used.
only when the company is in a place of low competitiveness.
(Wrenn 2002). The phase in which American hospitals are passing, in terms of marketing, can be characterized as "childhood" The study is a exploratory cross-sectional study, with primary data (Robbins, Kane and Sullivan 1988).
collection performed in 2007, made with hospital administrators, The marketing actions of the Brazilian hospital market, when using a questionnaire structured type, with closed questions.
they exist, are clearly orientated towards services production and Hospitals were selected by the master file of CNES – Cadastro towards "product" – the patient assistance process. More recently, Nacional dos Estabelecimentos de Saúde do Ministério da Saúde in the last few years, the hospitals considered as "top" or "first do Brasil. We included in this study the hospitals which fitted the class", started turning their marketing actions to service sales following criteria:  Hospitals located in the city of São Paulo – SP.
 Private for-profit and nonprofit hospitals, including the philantropic ones.
Main objective  Hospitals which provide healthcare to health plans and to 1. Verify the existence and analyse the marketing actions in private private patients-beds "non SUS" in the terminology and 30 World Hospitals and Health Services Vol. 46 No. 4
30-33 Blay:28 7/1/11 10:33 Page 31 Management: hospital marketing classification of CNES (at least one bed).
 Hospitals classified as hierarchy level 6 or 7 (median Marketing is still seen with some complexity), or 8 (high complexity), according to the skepticism by some administrators of terminology and classification of CNES.
the health area, who imagine that it is necessary only when the company Data are confidential and the project of the work was approved is in a place of low competitiveness by the Ethics Committee in Research of UNIFESP.
The answers of the questionnaire were tabulated and analised from the statistical point of view, with the factorial and Clusteranalysis.
prevalence of 13 (48,1%) to the General Board of Directors.
The mean number of collaborators who work in the marketing The sample considered was the one of 35 (30.4%) hospitais in area is 8. The hierarchy level with the highest mean number of relation to the total universe of 115 hospitals.
collaborators, 12 (29.4%), is the one of Assistant.
It was observed that the highest index of answers was in the It was questioned in which definitions and actions of the hospital range of hospitals with more than 200 beds: 12 (85.7%) and that there is one active and decisive participation of the marketing area.
the lowest index ocurred in the range of hospitals with 50 to 99 We noticed that the action in which this participation is more beds: 4 (14.8%).
frequent is the choice and definition of the type of release and of Of the respondent hospitals, 20 (57.2%) are for-profit and 15 the media used. In the budget of marketing actions, there is no (42.8%) are nonprofit hospitals. Among the for-profit hospitals, 3 participation of the marketing area in any hospital.
(8.6%) belong to a Health Agency, and all these 3 have more than It was also questioned the time of existence of the hospital 100 beds. We noticed that 26 (76.5%) are general hospitals and marketing area, observing that in hospitals with up to 50 beds, in that from the large-sized hospitals – 200 or more beds, 11 (91.7%) 1 (25.0%) the area is more than 5 years old; while in hospitals with are general.
more than 200 beds, in 8 (72.7%) the area is more than 5 years When asked about the level of importance of investments of the hospitals in items and tools the success of the hospital, we We have to keep in mind that 94.3% of the respondent hospitals observed that 33 (94.3%) of the general group of respondents were founded more than 5 years ago. attributed to the items listed, the levels "extremely important" or In the general group of respondents, 19 (67.9%) affirmed there is a budget for the hospital marketing actions. In the hospitals with When this evaluation was made in relation to the processes of up to 50 beds, 2 (50.0%) answered there is this budget; while in decision making, we observed that 31 (88.6%) of respondents of the ones with more than 200 beds, there were 8 (72.7%) positive the general group of hospitals attributed to the items listed, the levels "extremely important" or "very important".
With reference to the value of this budget, in relation to the billing The answers to the question about to which public they direct of the hospital, the average informed by the general group of their hospital marketing actions and the attribution of the level of hospitals was 1.5%. importance to each one we can notice that high levels of About the existence or not of a marketing plan established in a importance were attributed to all. Considering the answers written document, the positive answers of the general group of "extremely important" and "very important", to the general group hospitals were 17 (63.0%). In the hospitals with up to 50 beds, of hospitals, 74.3% was attributed to community; and to the other there were 2 (50.0%) positive answers; and in the ones with more publics, between 82.9% and 91.7%.
than 200 beds, there were 6 (60.0%).
With reference to the media used, we can observe a higher use The last question of the questionnaire was: In case there is a of more simple media, shown by the level of use in "stationery", 28 marketing plan, this plan is or is not integrated with the values/ (80.0%); against 1 (2.9%) use of subscription TV.
principles, mission, vision and objectives of the hospital? There With reference to the existence or not of a structure responsible were 17 (77.3%) positive answers in the general group of for the hospital marketing, in the general group of hospitals, 27 (77.1%) answered that there is one. From the range of hospitalswith up to 50 beds, 4 (57.1%) answered that there is such structure; and from the hospitals with more than 200 beds, 10 The statistical data analysis showed that the hospitals researched (83.3%) affirmed the existence of this structure. were clearly divided in two clusters, whose differentials are From the answers to the question about the hierarchy level of statistically significant, according to the factorial analysis and to the hospital marketing area we can observe that only in the the k-means cluster analysis performed: hospitals with more than 100 beds there is a Board of Directors/  good infrastructure and equipment, with well-defined Marketing Superintendency and that prevails, with 11 (35.5%) investment policy in marketing; hospitals of the general group, the Management level.
 worse infrastructure and less equipment, with lower It was also questioned the subordination of the marketing area proportional investment in marketing.
in the hospital, which showed that in only one hospital of thegeneral group of respondents, with more than 200 beds, the Of the 35 respondent hospitals, 15 (42.9%) fitted in group 1; marketing area is subordinated to a Management. In all the other and 20 (57.1%), in group 2.
cases, this area is subordinated to the Presidency, General Board The ones which fitted in group 1, in general, are the hospitals of Directors or Board of Directors/Superintendency, with colloquially called "first class"; on the other hand, we notice that World Hospitals and Health Services Vol. 46 No. 4 31
30-33 Blay:28 7/1/11 10:33 Page 32 Management: hospital marketing the marketing area; while in group 2, 4 (20.0%) hospitals did it. The result of a well planned and Eleven (80.0%) of the hospitals of group 1 and four (30.0%) of well implemented marketing the hospitals of group 2 declared the existence of a documented strategy is the attraction for marketing plan.
new clients, which generates a With these original findings of this work, it is demonstrated that group 1 of hospitals have a physical infrastructure (beds), higher billing, higher capacity technological (equipment) and of personnel significantly more of investment, not only in new advanced, in relation to the ones of group 2, or else, they are services, infrastructure and hospitals which have a better capacity of investment, what is one of the indicators of financial success. This same group shows abetter defined marketing strategy, in terms of planning and withhigher investment, proportionally to the hospitals of group 2.
not all the hospitals which have this differentiated image fit in The result of a well planned and well implemented marketing strategy is the attraction for new clients, which generates a higher In terms of structure and service, the hospitals of group 1 billing, higher capacity of investment, not only in new services, significantly differentiate from the hospitals of group 2, mainly in infrastructure and equipment, but also in marketing and so on, relation to items that are not considered so essential by the market forming a "virtuous circle" of success of the hospital enterprise; and that at the same time demand high investments, such as but as it was already mentioned, this is only a hypothesis to be nuclear medicine, magnetic resonance and tomography. We tested in the future, once this work does not clarify this question. should keep in mind that this type of service requires, besides the The question of the questionnaire about the participation "active financial investment in the purchase, installation and maintenance and decisive of the marketing area" shows that there is only this of the equipment; investment in people and in adequacy for the type of more intense participation, concerning the "choice and physical space. Such resources are scarce for a good part of definition of the type of release and media" (68.6% of hospitals in private hospitals in the city of São Paulo.
a general sample), "evaluation of public satisfaction" and In other structural and service items, which involve lower "relationship and internal and external communication" (both with complexity or constitute minimum necessary services for the operation of a general hospital, the differences between groups 1 This shows a narrow view (or "myopic") of marketing by the side and 2 are much smaller: Admission, Surgical Suite, ICU/CCU and of the hospitals, that do not put into practice the concept of "marketing compound", formed by the equitable application of the In case of "Day hospital", this service exists in a higher 4 "Ps", as they consider the marketing area as having only the "P" proportion in hospitals of group 2, probably because it is an of Promotion, neglecting the other "Ps", such as Pricing of admission of low complexity, of lower interest from the hospitals of products and services (20.0% of the general sample of hospitals) group 1, that invest in infrastructure, technology and skilled and the choice and definition of Products and services (28.6%). personnel for more complex services.
In relation to the media used, we notice significant differences in the use of media of higher cost and impact: outdoor (forbidden at  This hospitals, in general, make marketing actions, and the the moment by a municipal law in São Paulo), newspaper, radio, most used are the evaluation of satisfaction of open TV and subscription TV. In the most simple media, such as patients/caregivers. telemarketing, direct mail, direct emails and stationery, we do not  The administrators attribute a significant level of importance to observe this difference.
the application of hospital marketing concepts.
The subscription TV is used only by one hospital, that belongs  With reference to the existence or not of a structure to group 1. In group 2, no hospitals use TV and only 5.0 % used responsible for hospital marketing, in the general group of outside (before the prohibition by the municipal legislation), hospitals, 27 (77.1%) answered that there is this structure. In magazines and radio.
relation to the hierarchy level of the person responsible for the In the analysis of relationship employees/beds, group1 of marketing area, prevails, with 11 (35.5%) of hospitals of the hospitals showed 1.9 times the relationship of group 2.
general group, the management level. None of the hospitals In the relationship employees of the marketing area/ total with less than 100 beds have a marketing director our number of employees, group 1 has 2.2 times the relationship of superintendent. In hospitals with more than 100 beds, 30.4 % have this type of executive. In the relationship employees of the marketing area/beds, group  The hospitals of the general sample consider as extremely or 1 has a relationship that represents 4.1 times the one of group 2.
very important audiences: patients and relatives (91.7% of This shows, in any of these perspectives, that there is hospitals), doctors (91.4%), collaborators (85.8%), health plans proportionally an investment in the structure of general personnel (82.9%) and community (74.6%).
and, specifically in the personnel of the marketing area,  The most used media are the most simple and of lower cost: significantly higher by the hospitals of group 1, when compared to stationery (80.0% of hospitals), direct mail (65.7%), the ones of group 2.
advertisements in magazines (65.7%), direct emails (62.9%) With reference to strategy and to marketing budget, the and advertisements in newspapers (54.3%). differences between the groups, as expected, are also significant,  The hospitals studied were clearly divided in two groups, once in group 1, 13 (86.7%) of the hospitals informed a budget for whose differentials are statistically significant: 32 World Hospitals and Health Services Vol. 46 No. 4
30-33 Blay:28 7/1/11 10:33 Page 33 Management: hospital marketing 1. Good infrastructure and equipment, with well defined policy of investment in marketing.
2. Worse infrastructure and less equipment, with lower Loures, Carlos A. da Silva (2003), "A study on the use of physical evidence to generate service quality perceptions: case studies of brazilian hospitals," master degree dissertation, proportional investment in marketing.
Faculdade de Administração, Economia e Contabilidade da Universidade de São Paulo.
There is significant statistical correlation between the higher Maya, Stella. (2005), "Marketing hospitalar cresce 20% em 2005," Diário Comércio, Indústria investment in marketing and the best infrastructure. To & Serviços, Sep 29, Coluna de Serviços. Robbins, Stephen A., Christopher M. Kane and Daniel J.Sullivan (1988),"The Amherst study of establish the cause-effect relation of this correlation could be hospital marketing practices," Journal of Health Care Marketing, 8 (1), 86-87. an issue to be developed in one next work. Wrenn, Bruce (2002), "Contribution to hospital performance: market orientation vs. marketing  Although they conceptually attribute a significant level of effort and lack of competition," Journal of Hospital Marketing Public Relations, 14 (1), 3-13.
importance to the application of hospital marketing concepts,the hospitals studied apply this concept, in practice, in arestricted way, focusing the participation of the marketingarea in issues basically linked to the release (advertising andpublicity), communication and evaluation of publicsatisfaction. J Eduardo Blay Leiderman Medicine, School of Medicine – SantaCasa of São Paulo. Postgraduate degree in BusinessAdministration. MBA and Professional Master Degree inEconomics and Health Management at Federal University of SãoPaulo (UNIFESP). Researcher of Center for Health EconomicsPaulista –CPES. Associate director of Assector – health caremanagement consulting firm. Jorge Luis Padovan – Economist graduated at University of SãoPaulo (USP). Master Degree in Human Nutrition (USP). PhD inPublic Health at Escola Paulista de Medicina/Federal University ofSão Paulo (UNIFESP) – in course. Researcher of Center for HealthEconomics Paulista – CPES Paola Zucchi – Medicine, Escola Paulista de Medicina/FederalUniversity of São Paulo (UNIFESP). Deputy Director, Center forHealth Economics Paulista – CPES. PhD in Public Health School ofPublic Health, University of São Paulo. Specialization in HospitalAdministration from the School of Business Administration fromFundação Getulio Vargas World Hospitals and Health Services Vol. 46 No. 4 33
34-36 Protsiv:28 4/1/11 13:31 Page 34 Clinical care: HIV/AIDS/TB Improving health workers' access toHIV and TB prevention, treatment, careand support services SOPHIA KISTING
MYROSLAVA PROTSIV
DIRECTOR, THE ILO PROGRAMME ON HIV/AIDS AND THE TECHNICAL OFFICER, HEALTH SERVICES AT SECTORAL WORLD OF WORK IN THE SOCIAL PROTECTION SECTOR ACTIVITIES DEPARTMENT AT INTERNATIONAL LABOUR SUSAN WILBURN
BSN, MPH, TECHNICAL OFFICER IN OCCUPATIONAL & ENVIRON- LEE-NAH HSU
MENTAL HEALTH AT THE WORLD HEALTH ORGANIZATION TECHNICAL SPECIALIST, THE PROGRAMME ON HIV/AIDS AND THE WORLD OF WORK OF THE INTERNATIONAL LABOUR ABSTRACT: The International Labour Organization (ILO) and the World Health Organization (WHO) jointly developed policy guidelinesfor improving health workers' access to HIV and TB prevention, treatment, care and support services. These 14-point policyguidelines support the key principles of the International Labour Standard concerning HIV and AIDS in the world of work adopted in2010. The joint guidelines cover issues on workers' rights, national legislation and social protection of health workers. In addition,the guidelines provide framework for workplace policies, programmes, and training. To ensure proper implementation, theguidelines also addressed issues of budget, monitoring and evaluation. Turning these policy guidelines into effective practicewould require advocacy to both the health and labour sectors, as well as the recognition of the important roles of health workers,employers of health services, and that of the Ministries of Health and Ministries of Labour.
The health sector has a vital responsibility in helping realize their employment, in the events they become infected. people's fundamental rights to health. The health services In response to this situation, the ILO and WHO jointly developed employers and management must protect the health and a 14-point HIV-TB policy guidelines on how to ensure the access rights of their own workers in order to ensure the public could of all health workers to HIV and TB prevention, treatment, care and benefit from optimal health services.
support services. Many countries are currently facing a severe shortage in their The guidelines have a solid base of evidence resulting from health workforce. Increasing workloads of the personnel in systematic literature reviews, studies of current practices in 21 healthcare facilities and resource-constrained working conditions countries, and international expert consultations organised by lead to great challenges in recruitment and retention of qualified both the WHO and ILO. health workers. This situation is further Figure 1: Collaboration between WHO and ILO on protecting health workers from aggravated in countries that are particularly occupational exposure to biological hazards affected by dual epidemics of Humanimmunodeficiency virus and Tuberculosis.
The high rate of HIV-TB co-infection in thesecountries drives an increasing demand onhealth services. It also increases the HIV andTB burden on health workers who areparticularly exposed to both infections on adaily basis in their work environment.
Although health workers are at the frontline of responding to HIV and TB care needs ofpeople, they have to deal with their own fearsof contracting both HIV and TB because oftheir work exposures. The situation isaggravated by the fact that health workersthemselves often do not have adequateaccess to HIV and TB services. They facestigma and discrimination as well as loss of 34 World Hospitals and Health Services Vol. 46 No. 4
34-36 Protsiv:28 4/1/11 13:31 Page 35 Clinical care: HIV/AIDS/TB make them operational.
Table 1: The 14-point joint policy guidelines Table 2: How ILO and WHO work together to protect health worker How ILO and WHO work together to protect health worker Strengthening national policies, laws and strategies through TREATIntroduce new or refine existing national policies that ensure priority access for ILO and WHO have a long-standing collaboration on HIV and AIDS responses, as health workers and their families to services for the prevention, treatment and care co-sponsors of the UNAIDS and in occupational health. for HIV and TB.
In June 2004 the Governing Body of the ILO decided on conducting a joint tripartite meeting of experts with the WHO on HIV and AIDS in Health Sector and Introduce new or reinforce existing policies that prevent discrimination against subsequently, in April 2005, the Joint ILO/WHO guidelines on health services and health workers with HIV or TB, and adopt interventions aimed at stigma reduction HIV and AIDS were adopted by the meeting. In September 2005, the WHO and ILO among colleagues and supervisors.
called together another joint tripartite expert consultation to develop a joint WHO/ILO guidelines on post-exposure prophylaxis to prevent HIV infection. This Establish schemes for reasonable accommodation and compensation, including, second joint guidelines was published in 2008.
as appropriate, paid leave, early retirement benefits and death benefits in the event In 2006, in response to the crisis in human resources for health, WHO, in of occupationally-acquired disease.
collaboration with ILO, conducted a sequence of formal consultations with ILO constituents that includes representatives of workers, employers and Enhancing workplace policies, programmes and trainings governments, as well as other stakeholders and partners. The process of Develop, strengthen or expand existing basic occupational health services for the guidelines development also included a 21-country study on health workers' entire health workforce so that access to HIV and TB prevention, treatment and access to HIV and tuberculosis health services. This initiative originated from the care can be realized.
Treat, Train and Retain (TREAT) strategy jointly launched by WHO, ILO and International Organization for Migration (IOM) in 2006 to support scale-up of HIV Develop or strengthen existing infection control programmes, especially with and AIDS services towards Universal Access and address the impact of HIV on the respect to TB and HIV infection control, and collaborate with workplace health and health workforce. In September 2009, an international WHO/ILO consultation on safety programmes to ensure a safer work environment.
policy guidelines to improve health workers' access to prevention, treatment and care services for HIV and TB took place in Geneva. And in July 2010, a joint Develop, implement and extend programmes for regular, free, voluntary, and ILO-WHO tripartite expert consultation endorsed these policy guidelines.
confidential counselling and testing of HIV, and TB screening, including addressing reproductive health issues, as well as intensified case finding in the families of health workers with TB.
Adapt and implement good practices in occupational health and the management The purpose of the guidelines is to give coherence to a of HIV and TB in the workplace from both public and private health care sectors, as compilation of existing clinical and policy guidelines to improve well as other sectors.
health workers' access to HIV and TB prevention, treatment, care Provide information on benefits and risks of post-exposure prophylaxis (PEP) to all and support services. Moreover, the new guidelines fill in the gaps staff and provide free and timely PEP for all exposed health workers, ensuring of previous guidelines, for instance they address specifically need appropriate training of PEP providers. to protect health workers from contracting TB in the workplace Provide free HIV and TB treatment for health workers in need, facilitating the and the need for TB infection control.
delivery of these services in a non-stigmatizing, gender-sensitive, confidential, and convenient setting when there is no staff clinic and/or their own facility does not The target audience of the new policy guidelines are policy offer ART, or where health workers prefer services off-site.
makers in the ministries of health and of labour; public and privatehealth sector employers and senior management; occupational In the context of preventing co-morbidity, provide universal availability of a comprehensive package of prevention and care for all HIV positive health workers, and infection control practitioners; all health workers, their including isoniazid prophylactic treatment and co-trimoxazole prophylaxis, with associations or unions. appropriate information on benefits and risks.
The joint guidelines cover: Develop and implement training programmes for all health workers: pre-service,  national frameworks including rights, other legislation and in-service and continuing education on TB and HIV prevention, treatment and care; social protection schemes; workers' rights and stigma reduction, integrating these into existing training programmes and including managers and worker representatives.
 workplace actions including policies, programmes and Budgeting, monitoring and evaluationEstablish and provide adequate financial resources for prevention, treatment, care  budget, monitoring and evaluation involving national and and support programmes to prevent the occupational or non-occupational transmission of HIV and TB among health workers.
Develop and implement mechanisms for monitoring the availability of the In line with the 2006 WHO World Health Report, the 2010 joint guidelines at the national level, as well as the dissemination of these policies and ILO-WHO guidelines are based on a broad definition of "health their application in the healthcare setting.
workers" which includes the providers of health services such as Disseminate the policies related to these guidelines in the form of codes of doctors, nurses, pharmacists, laboratory technicians, as well as practices and other accessible formats for application at the level of health management and support workers in healthcare settings such as facilities, and ensure provision of budgets for the training and material inputs to make them operational.
finance officers, administrators, cooks, drivers, cleaners andsecurity guards1. The policy guidelines cover health workersemployed at all types of facilities, including acute-care, long-term The guidelines aim to protect health workers and empower care, community-based care, home-care and informal caregivers them to respond to the threat of HIV and TB infections.
or providers of health services in other sectors.
Implementing these guidelines could improve retention of health The guidelines illustrate for the health sector the fundamental workers and prevent the loss of health workforce due to infection rights and principles contained in the ILO Recommendation with HIV, TB or death. concerning HIV and AIDS and the World of Work, 2010, No. 200, The guidelines complement and reinforce guidelines previously by promoting, among others: developed by WHO and ILO on TB infection control3 and HIV in the  workers' rights; workplace4,5, health-systems strengthening6, post-exposure prophylaxis7,8,5, clinical diagnoses and treatment for HIV and TB10,  the active participation of health workers, their representatives reproductive health11, and occupational health12-14.
and health sector employers; World Hospitals and Health Services Vol. 46 No. 4 35
34-36 Protsiv:28 4/1/11 13:31 Page 36 Clinical care: HIV/AIDS/TB  the involvement of people living with HIV or TB; 1. The World Health Report 2006: Working together for health, (2006), Geneva; World Health effectiveness and efficiency.
2. Taegtmeyer M, Suckling R, Nguku P, Meredith C, Kibaru J, Chakaya J, et al. Working with The joint policy guidelines have been agreed to by the tripartite risk: Occupational safety issues among health care workers in Kenya. AIDS Care2008;20(3):304-10 constituents of ILO and approved by the Guidelines Review 3. WHO Policy on TB Infection Control in Health-Care Facilities, Congregate Settings and Committee of WHO. The guidelines were adopted by the Governing Body of the ILO in November 2010. They are officially 4. International Labour Office (ILO), World Health Organization (WHO). Joint ILO/WHO guidelines on health services and HIV/AIDS. available at: launched as part of the World AIDS Day celebration 2010. WHO and ILO encourage all their global partners to disseminate and 5. International Labour Conference Ninety-ninth session. Recommendation concerning HIV and implement this set of guidelines. For instance, to incorporate the AIDS and the world of work, 2010 (No.200), ISBN 978-92-2-123819-5, July, 2010. Availableat www.ilo.org/AIDS joint ILO-WHO policy guidelines for health workers into the 6. International Labour Office (ILO). Technical and ethical guidelines for workers' health International Hospital Federations' Positive Practice Environment 7. World Health Organization (WHO), International Labour Office (ILO). WHO-ILO Guidelines on post-exposure prophylaxis (PEP) to prevent HIV infection. Available at: Sophia Kisting, MD is the Director of the ILO Programme on HIV/AIDS and the World of Work in the Social Protection Sector. 8. World Health Organization (WHO). Occupational health: a manual for primary health care workers. Available at: She is an occupational medical specialist with extensive experience in workplace tripartite structure, occupational health and 9. World Health Organization (WHO). Antiretroviral therapy for HIV infection in adults and compensation issues. She has numerous publications. The adolescents. available at http://www.who.int/hiv/pub/guidelines/adult/en/index.html, 2006 10. International labour Office (ILO). ILO Code of Practice on HIV and the World of Work. Report Journal of Epidemiology and Community Health recognized her as one of ten influential women internationally in occupational health 11. World Health Organization (WHO). Integrating gender into HIV/AIDS programmes in the health and safety. kisting@ilo.org at ILO, Geneva, Switzerland sector: Tool to improve responsiveness to women's needs. Available at:http://www.who.int/gender/documents/gender_hiv/en/index.html, 2009 12. Joint ILO/WHO Committee on Occupational Health, with support of the Finnish Institute of Susan Wilburn, BSN, MPH is a technical officer in occupational & Occupational Health (FIOH). Basic Occupational Health Services. Available at: environmental health at the World Health Organization responsible http://www.who.int/occupational_health/publications/bohsbooklet.pdf: Jorma Rantanenauthor, Suvi Lehtinen editing, 2005 for health worker occupational health and "greening" the health 13. World Health Organization (WHO). Global Plan of Action on Workers' Health, 2008-2017.
sector. Ms. Wilburn, the past coordinator of the Centre for Occupational & Environmental Health at the American Nurses 14. World Health Organization (WHO). Guidelines on quality management in multidisciplinary Association, is the author of numerous articles on protecting health occupational health services. Available at: workers from occupational hazards. wilburns@who.int, at WHO, 15. Collier A, Van der Borght S, Rinke de Wit T, Richards S, Feeley F. A successful workplace program for VCT and treatment of HIV/AIDS at Heineken, Rwanda. International Journal ofOccupational & Environmental Health 2007;13(1):99-106 Lee-Nah Hsu, DSc, JD is a technical specialist at the Programme 16. Morris C, Cheevers E. A package of care for HIV in the occupational setting in Africa: Results on HIV/AIDS and the World of Work of the International Labour of a pilot intervention. AIDS Patient Care and STDs 2001;15(12):633-40 17. Corbett E, Dauya E, Matambo R, Cheun Y, al. e. Uptake of Workplace HIV Counselling and Organization responsible for health sector issues. She is a Testing: A Cluster-Randomised Trial in Zimbabwe. PLoS Med 2006;3(7):e328 specialist in health systems strengthening and previously served on 18. Dahab M, Charalambous S, Hamilton R, Fielding K, Kielmann K, Churchyard GJ, et al. "That Technical Review Panel of the Global Fund to fight AIDS, TB and is why I stopped the ART": patients' & providers' perspectives on barriers to and enablers ofHIV treatment adherence in a South African workplace programme. BMC Public Health Malaria and GAVI health systems strengthening review committee. hsul@ilo.org, at ILO, Geneva, Switzerland 19. UNAIDS. HIV stigma and discrimination: A summary of recent literature, 200920. International Labour Office (ILO). Technical and ethical guidelines for workers' health Myroslava Protsiv, BSW, MPH is a technical officer on health services at Sectoral Activities Department at International Labour 21. Makombe S, Jahn A, Tweya H, Chuka S, Yu J, Hochgesang M, et al. A national survey of the Organization. A recent graduate of Global Health master impact of rapid scale-up of antiretroviral therapy on health-care workers in Malawi: Effectson human resources and survival. Bulletin of the World Health Organization, 2007; 85(11): programme at Karolinska Institute, she has practical and research experience in human resources for HIV prevention and AIDS 22. Rezanson K, Pouteau K, Mnthambala A, Stephany P, Chiwewe D, Kumumbala R, et al. Do control. g4sector@ilo.org at ILO, Geneva, Switzerland health care workers with HIV/AIDS have delayed initiation of antiretroviral therapy andhigher mortality when compared with other patients in Malawim, XVI International AIDSConference, Toronto, Canada, 2006 36 World Hospitals and Health Services Vol. 46 No. 4
37-39 Translations 28:38 4/1/11 13:37 Page 37 World Hospitals and Health Services 2010 Volume 46 Number 4 Résumés en Français QUALITE ET CULTURE DE LA SANTE parties. D'abord, je rappelle la définition de la conception Les services de santé ont pour cadre une culture de la maladie qui hospitalière et de ses caractéristiques principales sous le régime émane essentiellement de la biologie, et consistent à soviétique. Ensuite, je présente deux exemples de modernisations diagnostiquer, guérir et réadapter. Les problèmes de santé d'hôpitaux en Ukraine et en Moldavie. Aux fins de comparaison, je montrent que les efforts déployés et les progrès réalisés dans le présente les acteurs de ces changements, les difficultés de domaine de la médecine ne suffisent pas. Perfectionner les modernisation d'un hôpital dues aux règlementations léguées par actions au sein de cette même culture paraît inefficace. Des les gouvernements antérieurs, ainsi que les solutions proposées changements sont nécessaires pour créer une culture de la santé.
pour instaurer les changements. Une introduction à la conception Les caractéristiques et le potentiel du travail infirmier ouvrent des hospitalière en Moldavie et en Ukraine permettra de mener une perspectives pour améliorer la qualité des soins, au cœur de la étude approfondie sur l'implication des acteurs internationaux dans les transformations post-communistes.
TROUVER UN EQUILIBRE ENTRE INTERETS NATIONAUX ET FACILITER L'ACCES DES AGENTS DE SANTE AUX SERVICES DE BESOINS DES PATIENTS : DES PROJETS SANS FRONTIERES PREVENTION, TRAITEMENT, SOINS ET SOUTIEN CONTRE LE QUI FONT FACE AUX DEFIS EUROPEENS VIH ET LA TUBERCULOSE Cet article est consacré aux nouvelles possibilités qui s'offrent aux L'Organisation internationale du travail (OIT) et l'Organisation citoyens des Etats-membres de l'UE d'aller à l'étranger pour un mondiale de la santé (OMS) ont élaboré ensemble des lignes traitement médical. La Court de Justice européenne a facilité directrices destinées à faciliter l'accès des agents de santé aux l'accès aux traitements médicaux dans d'autres Etats-membres services de prévention, de traitements, de soins et de soutien par les citoyens de l'UE. Cette mesure inquiète les gouvernements contre le VIH et la tuberculose. Ces directives en 14 points nationaux qui craignent de perdre le contrôle de leurs systèmes de s'appuient les principes de base des Normes Internationales du santé. Le projet inter-frontières "Healthacross" entre l'Autriche et la Travail relatives au VIH et au sida dans le monde du travail République Tchèque démontre néanmoins comment les autorités adoptées en 2010. Ces directives communes portent sur des peuvent répondre aux besoins des patients dans deux pays questions de droit des travailleurs, de législations nationales et de différents. Toutefois, il faudra résoudre une pléthore de problèmes protection sociale des agents de santé. En outre, les directives pratiques ou administratifs pour permettre une coopération définissent le cadre des politiques, programmes et formations sur internationale pour la délivrance de soins de santé.
les lieux de travail. Pour assurer une mise en œuvre correcte, lesdirectives examinent également les questions de budget, de suivi LES SOINS CENTRES SUR LE PATIENT : BIEN PLUS QUE LA et d'évaluation. L'application de ces directives dans le quotidien SOMME DES PARTIES - PROGRAMME PLANETREE DE nécessitera de plaidoyer dans les secteurs de la santé et du travail, DESIGNATION DES HOPITAUX CENTRES SUR LES PATIENTS et la reconnaissance des rôles importants des agents de santé, du Bon nombre d'hôpitaux aspirent à être mieux centrés sur les patronat de services de santé et des ministères de la santé et du patients, maintenant que ce concept commence à attirer l'attention, notamment sous l'aspect d'un sondage deconsommateurs disponible au public et une législation nationale PREPARATIONS AUX SITUATIONS D'URGENCE, GESTION DES de réforme des soins de santé comportant des incitations CRISES ET CAPACITE OPERATIONNELLE : LES HOPITAUX financières. Dans son programme de désignation, l'objectif de Planetree est de faire des soins centrés sur le patient une notion Les situations d'urgence qui se sont déclarés au cours des moins ambiguë et un objectif plus accessible. Le programme de dernières décennies montrent que l'état de préparation des désignation fournit un cadre d'évaluation des systèmes et organisations permettant de prévoir et de répondre aux procédures d'un hôpital, basé sur les trois décennies de recherche catastrophes est directement proportionnel à leur niveau de de Planetree, et plus particulièrement sur les données réunies capacité et de préparation à la gestion des crises. A cet égard, par auprès des panels de consommateurs. En partant de ces rapport à d'autres organisations, les hôpitaux sont mieux armés perspectives, Planetree a défini 50 critères en 11 catégories.
pour faire face à une catastrophe. Cette étude examine lescapacités opérationnelle d'hôpitaux publics et leur capacité de CONCEPTION HOSPITALIERE PRE- ET POST-SOVIETIQUE EN réponse aux situations d'urgence possibles. Les réponses des UKRAINE ET EN MOLDAVIE directeurs et gestionnaires d'hôpitaux montrent que la plupart Cet article examine le développement de la conception d'entre eux ne sont pas familiarisés avec la gestion des crises, hospitalière post-soviétique par une analyse de récentes bien que la plupart d'entre eux aient déclaré qu'ils avaient un plan modernisations en Moldavie et en Ukraine. Il se compose de deux et un comité de gestion des urgences dans leur hôpital. Par World Hospitals and Health Services Vol. 46 No. 4 37
37-39 Translations 28:38 4/1/11 13:37 Page 38 ailleurs, la plupart des interviewés pensaient qu'en cas de crise au changements radicaux du système de santé américain et la sein de l'hôpital, les patients, le personnel et les documents convergence de la télé-santé, des dossiers cliniques seraient les premières victimes de la crise. L'étude montre électroniques et des échanges d'informations médicales.
également qu'avoir un plan et un comité de crise sans bien Cet article examine les nouvelles tendances et les difficultés connaître la gestion des crises ne sera d'aucune utilité pour aider récemment rencontrées ainsi que les opportunités qu'elles les gestionnaires à faire face aux situations d'urgence. Par ailleurs, présentent en termes de progrès des solutions médicales basées les corrélations montrent que les gestionnaires plus âgés sur les télécommunications et les infrastructures de haut débit connaissent mieux les expériences de gestion de crise hors de leur rendues disponibles par les réseaux de télémédecine. Il examine pays, et que des responsabilités bien définies facilitent la mise sur également de façon approfondie les diverses applications de la pied de comités de crises, et la capacité de prendre au sérieux les télé-santé et les modèles de services de télémédicine les plus courants, ainsi que le rôle du réseau télémédical et des Centres deRessources Télémédicales (Telehealth Resource Centers,TRC) Rencontre de la télémedicine, des dossiers cliniques dans le développement de ces initiatives cruciales et de leurs électroniques et des échanges d'informations médicales.
possibilités d'accès pour les communautés isolées. Il s'appuie Des initiatives pour les communautés rurales notamment sur l'exemple du REACH Montana Telehealth La rencontre de diverses innovations a conduit à des World Hospitals and Health Services 2010 Volume 46 Number 4 Resumen en Espanol LA CALIDAD Y LA CULTURA EN MATERIA DE SALUD de la salud funcione.
Los cuidados de salud tienen como marco una cultura deenfermedades que se basan principalmente en la biología y que ASISTENCIA CENTRADA EN EL PACIENTE: ALGO MAS QUE LA sirven para: diagnosticar, curar, prevenir y rehabilitar. Los SUMA DE TODAS SUS PARTES – EL PROGRAMA PLANETREE problemas de la salud ponen de relieve que ni los esfuerzos ni los PARA DESIGNAR A UN HOSPITAL COMO ESTABLECIMIENTO grandes adelantos de la medicina son suficientes. El mejorar las CENTRADO EN EL PACIENTE medidas dentro de esta misma cultura no parece dar resultado Conforme el concepto de la asistencia centrada en el paciente alguno, es necesario introducir una reforma con el fin de crear una recibe mayor atención, hay numerosos hospitales que aspiran a cultura en materia de salud. Las características de la labor del adoptar este sistema, especialmente en lo que respecta a una personal de enfermería y su potencial abren nuevas oportunidades encuesta de mercado disponible públicamente y a la legislación para mejorar la calidad de los cuidados de salud, teniendo por sobre las reformas de la seguridad social, además de los centro la VIDA.
incentivos financieros. El objetivo del programa Planetree,destinado a nombrar a un hospital como establecimiento centrado COMO LOGRAR UN EQUILIBRIO ENTRE LOS INTERESES en el paciente, consiste en conseguir que el concepto deje de ser NACIONALES Y LAS NECESIDADES DEL PACIENTE: PROYECTOS tan ambiguo y pase a convertirse en un objetivo más fácil de TRANSFRONTERIZOS QUE HACEN FRENTE A LOS RETOS conseguir. Este programa sirve de marco para evaluar los sistemas y procedimientos de los hospitales y se trata de un proyecto Este artículo trata de las nuevas oportunidades para los basado en las tres décadas que Planetree lleva dedicado a esta ciudadanos de los estados miembros europeos para trasladarse a labor y especialmente a la información recopilada entre una serie otro país con el fin de recibir tratamiento médico. El Tribunal de de grupos específicos. Haciendo uso de estas perspectivas, Justicia Europeo ha facilitado el acceso al tratamiento médico para Planetree formuló 50 criterios dentro de 11 categorías.
los ciudadanos de un estado europeo en otro de la misma Unión.
Esta norma es motivo de preocupación entre los distintos TRANSFERENCIA INSTITUCIONAL DE LAS PRACTICAS gobiernos puesto que temen que representará una reducción del EUROPEAS A UCRANIA Y MOLDAVIA: EL CASO DEL DISEÑO control que ejercen sobre su propio sistema de salud. El proyecto transfronterizo denominado "healthacross" (salud en todas partes) Este artículo examina el curso del diseño hospitalario en la época entre Austria y la República Checa es un ejemplo de la manera en postsoviética mediante un análisis de la reciente modernización de la que las autoridades pueden responder a las necesidades del Moldavia y Ucrania. El informe consta de dos partes. En primer paciente en dos países distintos. No obstante, hay toda una serie lugar, una definición del diseño hospitalario y sus principales de problemas de carácter administrativo y práctico que solucionar características durante la época soviética. En segundo, el ejemplo para este proyecto transfronterizo de cooperación en la prestación de dos modernizaciones hospitalarias en Ucrania y Moldavia.
38 World Hospitals and Health Services Vol. 46 No. 4
37-39 Translations 28:38 4/1/11 13:37 Page 39 Dentro de una perspectiva comparativa, hago una presentación pueden sufrir más daños cuando se produce un desastre. Este de los actores implicados en el caso, las dificultades en cuanto a informe investiga el nivel de aptitudes y estado de preparación de la modernización del hospital en lo que respecta al reglamento los hospitales públicos para manejar los desastres. De las anterior, así como las soluciones avanzadas con el fin de poner en respuestas de los gerentes y directores de los hospitales se práctica ese cambio. Una introducción al diseño hospitalario en desprende que si bien muchos de ellos no están familiarizados Moldavia y Ucrania permitirá llevar a cabo un estudio a fondo de con el control de emergencias, la gran mayoría admiten que sus la implicación de actores internacionales en las transformaciones hospitales cuentan con un programa y un comité para el control de emergencias. Lo que es más, la mayoría de los cuestionadosopinan que en el caso de ocurrir un desastre en el hospital, los COMO MEJORAR EL ACCESO DEL PERSONAL SANITARIO A LA pacientes, el personal y los documentos serían los primeros en PREVENCION, EL TRATAMIENTO, LOS CUIDADOS Y LOS sufrir las consecuencias. Los resultados del informe demuestran SERVICIOS DE APOYO DEL VIH Y LA TUBERCULOSIS además que el contar con un programa de emergencias o un La Organización Internacional del Trabajo (OIT) y la Organización comité de crisis sin estar familiarizado con conocimientos para el Mundial de la Salud (OMS), han redactado conjuntamente una control de emergencias no ayuda a los gerentes a hacer frente a serie de normas de política con miras a mejorar el acceso del una situación de crisis. Además, la correlación demuestra que los personal sanitario a la prevención, el tratamiento, los cuidados y gerentes con más experiencia están más familiarizados con los servicios de apoyo del VIH y la tuberculosis. Se trata de 14 experiencias sobre el control de emergencias en el extranjero y normas de apoyo a los principios más destacados de las Pautas destacan que las responsabilidades contribuyen para el de la Organización Internacional en cuanto al VIH y el SIDA, en la establecimiento de los comités de crisis y para tomar las esfera laboral, adoptadas en 2010. Estas normas conjuntas situaciones de crisis con mayor seriedad.? comprenden asuntos relativos a los derechos de los empleados,la legislación nacional y la protección social del personal sanitario.
LA ENCRUCIJADA DE LA TELE-SALUD, LAS HISTORIAS Por otro lado, las pautas constituyen un marco para las políticas, CLINICAS ELECTRONICAS Y EL INTERCAMBIO DE programas y formación en el lugar de trabajo. Con el fin de INFORMACION SANITARIA. LA PLANIFICACION DE LAS garantizar una puesta en práctica adecuada, las normas tratan COMUNIDADES RURALES además otras cuestiones relacionadas con los presupuestos, el Hay una serie de circunstancias que está dando lugar a una seguimiento y la evaluación. Para convertir estas normas en una reforma radical del sistema de salud de los Estados Unidos y práctica eficaz se requiere el apoyo, tanto hacia la esfera de la produciendo una convergencia de tele-salud, historias clínicas salud como la laboral, además del reconocimiento del papel tan electrónicas (en inglés EHRs) e intercambio de información importante que desempeñan los empleados de la salud, el sanitaria (en inglés HIE).
personal de los servicios sanitarios en general y el de los Este artículo examina las tendencias emergentes, así como los Ministerios de Sanidad y Trabajo.
aspectos perjudiciales y estudia las oportunidades que ofrecenpara el avance de las soluciones sanitarias basadas en las CONTROL DE EMERGENCIAS, APTITUDES Y ESTADO DE telecomunicaciones y la infraestructura de banda ancha PREPARACION: EL CASO DE LOS HOSPITALES PUBLICOS DE disponible a través de las redes de tele-salud. También hace un examen minucioso de los distintos usos de la tele-salud y los Los desastres ocurridos en las últimas décadas indican que el ejemplos más corrientes de prestación de la tele-medicina, así estado de preparación de las organizaciones para predecir y como el papel que desempeña el sistema de la tele-salud y los reaccionar ante ciertos problemas inesperados está directamente Centros de Recursos Tele-sanitarios (en inglés TRCs) para ampliar relacionado con el nivel de sus aptitudes y el estado de el alcance de estas iniciativas tan importantes. El informe pone de preparación para controlar las emergencias. En este sentido, en relieve la Red tele-sanitaria REACH Montana.
comparación con otras organizaciones, son los hospitales los que World Hospitals and Health Services Vol. 46 No. 4 39
40-42 Company profiles:28 7/1/11 10:35 Page 40 IHF corporate partners is a global leader in professional services, providing award-winning food services, management of facilities, assets, and clinicaltechnology, and uniform/career apparel to health care institutions and other businesses. In FORTUNE magazine's 2010 list of "World'sMost Admired Companies," ARAMARK ranks number one in its industry, consistently ranking since 1998 as one of the top three mostadmired companies in its industry. ARAMARK seeks to responsibly address key issues by focusing on employee advocacy,environmental stewardship, health and wellness, and community involvement. Headquartered in Philadelphia, Pennsylvania (USA),ARAMARK's 255,000 employees serve clients in 22 countries.
Visit www.aramark.com is the centre of a community comprised of over 15,000 players of the hospital business. Through our web platform, we integratehospitals throughout the supply chain sector, focusing on business development and relationships. Established in 2000, in just 10years, Bionexo was structured in Brazil, becoming the largest marketplace reference to the hospital industry and contributingsignificantly to the professionalization of the purchasing sector and growth of the healthcare market.
The success of this innovative business model has led to Bionexo for Latin America and Europe, where also attained leadership inaddition to export technology and implement a new concept in commercial transactions of organizations. Everything happened in ashort time, just like businesses are made between the companies that integrate our platforms. This makes Bionexo the largest core ofthe hospital sector in Brazil. Pioneering and innovation, helping thousands of companies and hospitals.
www.bionexo.com.br is the world leader in GIS technology. On any given day, more than one million people around the world use ESRI geographicinformation system (GIS) software to improve the way their organizations conduct business. ESRI GIS solutions are becoming anintegral component of health organizations in addition to nearly every other type of business and government service.
By adding a geographic component to data and analysis, ESRI software promotes exploring, analyzing and visualizing massive amountsof information according to spatial relationships. Since most health and human service problems facing the world today exist in alocation-based context, geography can play a major role in helping health professionals understand health dynamics and the spread ofdisease. Health surveillance systems are used to gather, integrate and analyze health data; interpret disease transmission and spread;and monitor the capabilities of health systems. GIS is the enabling technology to spatially relate much of the information, making it apowerful tool for identifying, tracking and responding to disease patterns and health service needs.
ESRI software is extensively used by health organizations throughout the world, including the US Centers for Disease Control and Prevention (CDC), the World Health Organization (WHO), 112 national health ministries, and over 500 hospitals.
www.esri.com/health 40 World Hospitals and Health Services Vol. 46 No. 4
40-42 Company profiles:28 7/1/11 10:35 Page 41 IHF corporate partners owns the Capital's six leading private hospitals all based in central London and each with an international reputation for the higheststandards of care. They are: The Wellington – the largest private hospital in Europe, The London Bridge Hospital, The Harley StreetClinic, The Portland Hospital for Women and Children, The Lister Hospital and The Princess Grace Hospital. HCA also has four outpatientand diagnostic centres – soon to be six – a blood and bone cancer treatment joint venture with the NHS at University College Hospital,The London Gamma Knife Centre, another joint venture with the NHS at St Bartholomew's Hospital and Harley Street at Queen's, aprivate patient cancer centre at the NHS Queen's Hospital in Romford.
The six HCA hospitals treat around 300,000 patients per year. They also specialise in the most complex medical procedures including cardiac care, liver transplantation, inter cranial surgery and complex cancer care. The HCA CancerCare network, for example, is thelargest provider of cancer care in the UK outside the NHS. Uniquely, HCA has its own clinical trials unit based in Harley Street in centralLondon. Medical teams in HCA are involved in research programmes aimed at finding new treatments in areas such as heart diseaseand cancer. In recent years HCA has invested around £250 million in capital expenditure including new diagnostic and treatmenttechnology. As an example, HCA has recently installed at The Harley Street Clinic, the revolutionary CyberKnife robotic radiotherapymachine, which is able to target previously untreatable tumours. It is the first machine of its kind in the UK.
www.hcainternational.com As the Inter-national division of Joint Commission Resources, Joint Commission International (JCI) has been working with health careorganizations, ministries of health, and global organizations in over 80 countries since 1994.
Our focus is on improving the safety of patient care through the provision of accreditation and certification services as well as through advisory and educational services aimed at helping organizations implement practical and sustainable solutions.
In fact, the world's first World Health Organization (WHO) Collaborating Centre, dedicated exclusively to patient safety solutions, is a joint partnership between the WHO, The Joint Commission, and JCI. We recently celebrated our tenth anniversary of the first hospitalaccredited by JCI, Hospital Israelita Albert Einstein, a private, non-profit, non-governmental facility in Sao Paulo, Brazil. Since then,more than 300 public and private health care organizations in 39 countries have been accredited by JCI. JCI provides accreditation forhospitals, ambulatory care facilities, clinical laboratories, care continuum services, medical transport organizations, and primary careservices, as well as certification for disease or condition specific care. JCI Consulting provides education and advisory services to healthcare organizations, ministries of health, accrediting bodies, and other entities outside of the United States. We provide practicalsolutions to help develop clinical services, improve the quality of care, enhance patient safety, reduce and manage risk, and achieveinternational standards. JCI currently has regional offices serving Asia Pacific, Europe and the Middle East.
www.jointcommissioninternational.org uses its 125 years of experience to help healthcare organizations create comfortable, safe and sustainable healing environments whileproviding measurable results. By utilizing our expertise in energy and sustainability, facilities, building and technology infrastructure,healthcare organizations can improve their financial results, the environment of care and their standing in the community. JohnsonControls provides design assist and construction management, funding solutions, network integration solutions for clinical and non-clinical systems, energy management and central utility plants, operations support and best practices, systems maintenance andfacility management services. Johnson Controls helps healthcare organizations create comfortable, safe and sustainable healingenvironments while providing measurable results.
www.johnsoncontrols.com World Hospitals and Health Services Vol. 46 No. 4 45
40-42 Company profiles:28 7/1/11 10:35 Page 42 IHF corporate partners a business of Ingersoll Rand – the world leader in creating and sustaining safe, comfortable and energy efficient environments –creates ideal environments of care for healthcare organizations all over the globe. Our products, services and solutions optimize thelink between the physical environment to patient outcomes, staff satisfaction/productivity and the bottom line.
Trane/Ingersoll Rand solutions optimize healing environments with a broad portfolio of energy efficient heating, ventilating and air conditioning systems, building and contracting services, parts support and advanced controls for healthcare buildings. Our market-leading products also include electronic and biometric access control systems; time and attendance and personnel schedulingsystems; mechanical locks and portable security, door closers and exit devices, steel doors and frames, architectural hardware andtechnologies and services for global healthcare markets.
www.Trane.com and www.ingersollrand.com is a leading US developer and operator of sustainable energy systems. Veolia Energy provides sustainable energy services, and facilityoperations and management to nearly 5,550 healthcare institutions in 42 countries around the world, representing almost 500,000beds.
Veolia Energy delivers solutions that enhance the economic, technical and environmental performance of complex systems and equipment within a hospital: energy supply, including on-site power generation for critical areas such as operating rooms,neonatology, and research and testing laboratories; steam for use in heating, sterilization, and service water heating; mechanicalrefrigeration facilities for food service and morgues; and more basic services such as HVAC, heating and cooling systems. Partneringwith Veolia Energy permits hospitals to transfer their operating risks to a firm that specializes in preventive and predictivemaintenance, energy optimization, and carbon footprint reduction.
Veolia Energy North America is part of the Veolia Environnement companies in North America, employing more than 28,000 North American personnel. Veolia Environnement (NYSE: VE and Paris Euronext: VIE), is the global standard for environmental services. Withapproximately 313,000 employees in 74 countries who deliver sustainable environmental solutions in water management, wasteservices, energy management, and passenger transportation, Veolia Environnement recorded annual revenues of nearly $50 billion in2009. Veolia Environnement is in the Dow Jones Sustainability World Index (DJSI World) and Dow Jones STOXX Sustainability Index (DJSISTOXX). Visit the company's Web sites at www.veoliaenergyna.com and www.veolianorthamerica.com.
42 World Hospitals and Health Services Vol. 46 No. 4
43-44 Governing council-diary:26 4/1/11 13:42 Page 43 IHF Governing Council 2009-2011 THE EXECUTIVE COMMITTEE
Immediate Past Presidents Mr GERARD VINCENT Dr JOSE CARLOS DE SOUZA Mr THOMAS C DOLAN FEDERATION HOSPITALIERE Former Commissioner for AMERICAN COLLEGE OF Health – Lagos State CONFEDERACAO NACIONAL HEALTHCARE EXECUTIVES for Health Insurance Affairs 1 bis Rue Cabanis House G40C, Road 2 One North Franklin Street MINISTRY OF HEALTH Victoria Garden City, Lagos SRTVIS Quadra 701, Chicago, Illinois 60606- PO Box 5, PIN Code 13001 Tel: +33 1 44 06 84 42 / 44 Tel: +234 1 775 4544 / +234 Edificio Palacio do Radio 1 Fax: +331 44 06 84 45 803 7787834 / +44 7785 Brasilia DF, CEP 70340-906 Tel: +965 2486 5415 / 3699 E-mail: g.vincent@fhf.fr / Fax: +965 2486 3524 Email: drlekepitan@ Tel: +55 61 3321 0240 Tel: +1 312 424 9365 Fax: +55 61 3321 0250 Fax: +1 312 424 0023 Email: cns@cns.org.br E-mail: tdolan@ache.org Dr JUAN CARLOS LINARES Dr ERIK KREYBERG NORMANN CAMARA ARGENTINA DE EMPRESAS DE HONG KONG HOSPITAL AUTHORITY Department of Hospital Services TAIWAN HOSPITAL ASSOCIATION Room 1003, Administration Block NORWEGIAN DIRECTORATE OF HEALTH Tucuman 1668, 2 Piso Queen Mary Hospital P.O.Box 7000 St. Olavs plass, N-0130 Sec. 2, Jung jeng E. Road Buenos Aires C.P. 1050 102 Pokfulam Road Danshuei Township, Taipei County Tel: +47 24 163 000 / 47 24 163 201 Tel: +54 11 4372 5915 / 5762 Tel: +852 2255 3253 Fax: +47 22 22 66 88 Tel: +886 22 808 3300 Fax: +54 11 4372 3229 Fax: +852 2504 2784 Email: erik.normann@helsedir.no Fax: +886 22 808 3304 E-mail: laifm@ha.org.hk Email: hatw@hatw.org.tw Prof CARLOS PEREIRA ALVES Prof HELEN LAPSLEY Dr MUKI REKSOPRODJO Mrs ALISON KANTARAMA Research Professor International Relations ASSOCIACAO PORTUGUESA PARA O CENTRE OF NATIONAL RESEARCH ON INDONESIAN HOSPITAL ASSOCIATION UGANDA NATIONAL ASSOCIATION OF DISABILITY & REHABILITATION MEDICINE (Portuguese Association for the Hospital HOSPITAL ADMINISTRATORS (UNAHA) University of Queensland PERHIMPUNAN RUMAH SAKIT SELURUH INDONESIA (PERSI) Av. António Augusto de Aguiar, 32-4º PO Box 7051, Kampala Mosman, Sydney NSW 2088 c/o Jl.H.R.Rasuna Said Kav.C-21 Kuningan Jakarta Selatan 12940 Tel: +256 414 554 748 Tel: +612 99 692 346 Tel: +351 217 92 5 823 / 5666 Fax: +256 414 532 591 Fax: +612 99 684 987 Tel: +6221 72791383 Mob: +351 963 668 745 Email: cliveh@ip.net.au Fax: +6221 7252026 Fax: +351 217 925 594 Email: reksoprodjo7muki@gmail.com Email: apdh.mail@gmail.com Mr ABDUL SALAM AL-MADANI Administrateur général Dr THABO LEKALAKALA CLINIQUES UNIVERSITAIRES SAINT-LUC Director - Hospital Management Dubai Healthcare City Avenue Hippocrate 10 JAPAN HOSPITAL ASSOCIATION Block B, Offices 203 – 303 B - 1200 Bruxelles 13-3 Ichibancho, Chiyodaku, Tokyo DEPARTMENT OF HEALTH P.O.Box 13636, Dubai Street Hallmark Building UNITED ARAB EMIRATES Tel: +32 2 764 15 22 Tel: +813 32 650 077 Tel: +97 14 362 4717 Fax: +32 2 764 15 25 Fax: +813 32 38 6789 Fax: +97 14 362 4718 Email: durant@hosp.ucl.ac.be Tel: +27 12 312 0930 Fax: +27 12 312 3388 SIR KEITH PEARSON Email: thabang.lekalakala@gmail.com GERMAN HOSPITAL FEDERATION KOREAN HOSPITAL ASSOCIATION NHS CONFEDERATION 35-1, Mapo-Dong, Mapo-Gu, Seoul 29, Bressenden Place Tel: +822 718 754 Ext 183 Tel: +49 30 398 011 001 Fax: +822 718 7522 Tel: +44 (0) 207 074 3200 Fax:+4930 398 013 011 Fax: +44 (0) 844 774 4319 Email: g.baum@dkgev.de Email: keith.pearson@nhsconfed.org World Hospitals and Health Services Vol. 46 No. 4 43
43-44 Governing council-diary:26 4/1/11 13:42 Page 44 Dates for your diary IHF NATIONAL HOSPITAL ASSOCIATION MEMBERS EVENTS DIARY: 2011
Switzerland
November – H+ Les Hôpitaux de Suisse
National Association congress
Bern, Switzerland
Tel: +41 (0) 31 335 11 33
reinhard.voegele@hplus.ch
www.hplus.ch / http://www.ihf-fih.org
8-10 November 2011
Dubai, Unites Arab Emirates
37th IHF World Hospital Congress*
info@ihf-fih.org
http://www.ihfdubai.ae/ http://www.ihf-fih.org
Events marked* are interpreted into English, French and Spanish. All other events will be in English/host country language only. IHF members will automatically receivebrochures and registration forms on all the above events approximately 6 months before the start date. IHF members will be entitled to a discount on IHF Congresses,pan-regional conferences and field study courses.
For further details contact the: International Hospital Federation, Immeuble JB Say, 13 Chemin du Levant, 01210 Ferney Voltaire, France; E-Mail: info@ihf-fih.org Or visit the IHF website: http://www.ihf-fih.org 44 World Hospitals and Health Services Vol. 46 No. 4
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Clinical practice in early psychosis Managing incomplete recovery during first episode psychosis IntroductionWhile the vast majority of young people who resistance. Thus concerted effort is required to develop a first episode of psychosis respond well address incomplete recovery from psychosis to initial treatment and have a remission of their

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Part 13: First Aid: 2010 American Heart Association and American Red Cross International Consensus on First Aid Science With Treatment Recommendations David Markenson, Jeffrey D. Ferguson, Leon Chameides, Pascal Cassan, Kin-Lai Chung, Jonathan L. Epstein, Louis Gonzales, Mary Fran Hazinski, Rita Ann Herrington, Jeffrey L. Pellegrino, Norda Ratcliff and Adam J. Singer