00 cover vol46.4.ai
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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,
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Institutional transfer from the European design practices to Ukraine and Moldova: the
■ Medical director
case of hospital design
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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
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Clinical careImproving health workers' access to HIV and TB
■ Laboratory director
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■ 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:
[email protected]
24 Institutional transfer from the European design practices to Ukraine and Moldova: the
case of hospital design Rodica Plugaru
Subscription OfficeInternational Hospital Federation
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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
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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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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
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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
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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
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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
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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
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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
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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
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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
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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.
14 World Hospitals and Health Services Vol. 46 No. 4
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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. [email protected] 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. [email protected], 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.
[email protected], 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. [email protected] 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.
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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:
[email protected] /
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:
[email protected]
E-mail:
[email protected]
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:
[email protected]
Fax: +886 22 808 3304
E-mail:
[email protected]
Email:
[email protected]
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:
[email protected]
Fax: +6221 7252026
Fax: +351 217 925 594
Email:
[email protected]
Email:
[email protected]
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:
[email protected]
Tel: +27 12 312 0930
Fax: +27 12 312 3388
SIR KEITH PEARSON
Email:
[email protected]
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:
[email protected]
Email:
[email protected]
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
[email protected] www.hplus.ch / http://www.ihf-fih.org
8-10 November 2011
Dubai, Unites Arab Emirates
37th IHF World Hospital Congress*
[email protected] 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:
[email protected] 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
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