Transcript BFS-Competency-6-7-Organizational

Competency 6 & 7: Health Care Delivery Systems
& Organizational Structure
Dede Carr, BS, LDA
Karen Neu, MSN, CNE, CNP
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Competency #6: Health Care Delivery
Systems & Organizational Structure
 Competency:
 Describe selected types of healthcare facilities/systems
including
 Organizational & financial structure
 Departments & services
 Types & levels of healthcare personnel
 Common policies and requirements.
Competency #7: Health Care Delivery
Systems & Organizational Structure
 Competency:
 Describe the different healthcare delivery systems
What is a health care system?
Levels of Health Care Services
What is a health care system?
Definition:
 “ The total services offered by all health disciplines and
the method to pay for them”
(Berman, Snyder, Kozier, & Erb)
Purpose of the health care system:
 Provide care for ill & injured
 Health promotion
 Illness & disease prevention
 Levels of wellness
Services categorized by types & levels of care
Healthcare Delivery System
Elements
Organizational Structure 1.
1.
1.
2.
2.
3.
Public: Government (Federal,
State, Local)
Private: For Profit/Non-Profit
Oversight & Management
Health Care Services
Finance Mechanisms
1.
2.
3.
4.
5.
Out of Pocket
Private Insurance
Managed Care Organizations
Public Insurance
Public Funding
2. Resources
Direct & Indirect Care
Public & Private Providers
1.
Facilities
Health Promotion & Disease
2.
Personnel
Prevention
3.
Equipment
4.
Treatment of Disease
4.
Supplies
5.
Rehabilitation/Special Needs 3. Recipient of Care
6.
Hospice/Adult Day Care
(Consumer:
Patients/Families/Populations)
(Berman et al.)
1.
2.
3.
Health Care
Delivery System Overview
Berman, A., Snyder, S.J., Kozier, B., & Erb, G. (2008). Health care delivery systems. In A. Berman, S.J. Snyder, B. Kozier, & G. Erb (Eds.). Kozier &
Erb’s Fundamentals of nursing: Concepts, process, and practice (8th ed.) (pp. 101-116). Upper Saddle River, NJ: Prentice Hall
Types of Healthcare Services
Levels of Prevention
Primary: Health promotion & disease prevention
 Immunizations/Vaccinations, Smoking Cessation
Secondary: Diagnosis & Early Treatment
 Screenings such as mammograms, PAP tests, mantoux
 Lifestyle changes to prevent disease, Ex. low cholesterol
diet, start a physical activity program, medications
Tertiary: Rehabilitation, Health Restoration, & Palliative Care
 Rehabilitation after a stroke or injury
 Comfort care for the terminally ill (Berman et al)
Primary Prevention
Actions to protect against disease & disability
 Focuses on “Health & Wellness” Not on “Illness”
 Immunizations,
 Ensuring supply of safe drinking water
 Applying dental sealants to prevent tooth decay
Actions to prevent accidents
 Government & state requirements for workplace safety
 Wearing seatbelts
 Not driving drunk
 Wearing proper protective equipment on the job
(Net Industries and its Licensors)
Primary Prevention
Health Promotion includes the basic activities of a
healthy lifestyle:
 Good nutrition & hygiene
 Adequate exercise
 Adequate rest
 Avoidance of environmental & health risks
 Limiting exposure to sunlight, using sunscreen, &
wearing protective clothing
(Net Industries and its Licensors)
Primary Prevention
Mental Health
 Teach children communication & interpersonal skills
 Conflict management
 Relationship & life skills that foster emotional
resiliency
Health Education Programs aimed at wellness:
 Stress management
 Parenting classes
 Preparation for retirement from the workforce
 Cooking classes (Net Industries and its Licensors)
Secondary Prevention
Goal of Secondary Prevention
 To identify & detect disease in its earliest stages, before
noticeable symptoms develop, when it is most likely to be
treated successfully.
 With early detection & diagnosis, it may be possible to cure a
disease, slow its progression, prevent or minimize
complications, & limit disability
 Prevent the spread of communicable diseases (illnesses that
can be transmitted from one person to another) (Example:
H1N1 Influenza, sexually transmitted diseases)
 Preventive services: screening to detect & identify wide range
of conditions: high blood pressure, depression, obesity, &
sexually transmitted diseases
 Screening in medical offices, clinics, schools, health fairs
(Net Industries and its Licensors)
Tertiary Prevention
Aim to improve the quality of life for people with various
diseases by
 Limiting complications & disabilities
 Reducing severity & progression of disease
 Providing rehabilitation (therapy to restore function & self-sufficiency)
Involves actual treatment for the disease & conducted primarily
by health care practitioners, rather than public health agencies
Possible to slow the natural course of some progressive diseases
and prevent or delay many of the complications associated
with chronic diseases such as arthritis, asthma, diabetes, &
heart disease
For mental health, have outreach programs that monitor persons
with mental disorders who live in the community to ensure
that they adhere to their prescribed medication regimens
(Net Industries and its Licensors)
Acute & Sub-acute Care Hospitals
Rehabilitation Centers
Extended Care Facilities
Medical, School, & Occupational Health Clinics
Community/Public Health Care Agencies
Home Health Care Agencies
Hospice & Palliative Care Agencies
Crisis Centers
Adult Day Care Centers
Types of Healthcare Delivery System
Agencies/Services
Hospitals
 Acute inpatient services
 Outpatient clinics/Ambulatory care services (ex. Same
day surgery)
 Emergency services/Urgent Care
Public Health
 Local, state, & federal levels (county & city level)
 Funding from taxes
 Preventative programs, direct patient care, protect the
public from outbreaks of disease (Berman et al)
Types of Healthcare Delivery
Systems Agencies/Services
Physicians’ Offices/Clinics
 May be primary care providers or general practitioners
 May be specialties: Dermatologist, Surgeons, Nurse
Practitioners
Occupational Health Clinics
 Worker safety & health; screenings
Sub-Acute Care Facilities
 Variation of inpatient care (after acute hospitalization
when still needing complex treatments) (Berman et al)
Types of Healthcare Delivery System
Agencies/Services
Extended Care (Long-Term Care) Facilities
 Independent living quarters
 Assisted living facilities
 Skilled nursing facilities (Intermediate Care)
 Extended Care (Long-term Care)
Retirement/Assisted Living Facilities
Rehabilitation Centers
 Physical & mental care
 Drug & alcohol, gambling treatment/rehabilitation
(Berman et al)
Types of Healthcare Delivery System
Agencies/Services
Home Health Care Agencies (Public/Private)
 Offer education; comprehensive care to acute, chronic, &
terminally ill patients, assistance with activities of daily
living: bathing, preparing meals)
Day-Care Centers: (many age groups)
 Ex. Elder Care: Socializing, exercise programs,
stimulation, counseling, physical therapy
Rural Care: Rural hospitals providing emergency care in
rural areas/comprehensive primary care across the
lifespan
Hospice Services: Services for terminally ill, their families
& support persons
(Berman et al.)
Types of Health Care Delivery
Systems Agencies/Services
Crisis Centers: Emergency services to clients
experiencing life crisis to help them cope with
immediate crisis, guidance & support for long-term
therapy
Mutual Support & Self-Help Groups: More than 500
mutual or self-help groups focusing on major health
problems or life crisis
School Health Centers
Mental Health Clinics
(Berman et al.)
Government , Public, and Private Funding Sources
Who pays for the healthcare
services we need?
For example, if you go to the doctor for a sore throat (strep
infection) that requires antibiotic medication who pays
for the services:
 Health care provider’s examination
 Laboratory test (throat culture)
 Antibiotic medication
 Not to mention others involved with a clinic visit, such as
the billing department, receptionists, medical record
technology?
Payment for Healthcare Services
See the following slides for various funding sources
for health care
 Keep in mind that each type of funding source
(insurance companies) covers specific services, some
may require a co-pay which means that the person
pays a small amount for each visit to the health care
provider or for emergency care, etc.
 Some plans cover preventative care such as: biannual
dental cleaning, annual physical examinations,
 What type of health care coverage do you have?
Financing Health Care
Governmental Funding
Group Insurance
 Medicare
 Medicaid
 State Childrens’ Health Insurance
 Health Maintenance
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
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Program (SCHIP)
Supplemental Social Security
Income
Minnesota Care
Veterans Health
Tribal Indian Health
Prospective Payment System
Private Insurance
Out-of-Pocket
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Organizations (HMOs)
Preferred Provider Organizations
(PPO)
Preferred Provider Arrangements
(PPA)
Independent Practice Associations
(IPAs)
Physician/Hospital Organizations
(PHOs)
Integrated Delivery Systems (IDS)
(Berman et al.)
Financing Healthcare
Medicare coverage
 Persons 65 years & older,
 Workers with permanent disabilities & their dependents
(receiving Social Security Disability Benefits)
 Medicare with supplemental insurance coverage
(Drug Program; Supplement pays for costs not covered by
Medicare)
Medicaid (paid by federal & state government [taxes])
Supplemental Security Income (Persons with
disabilities, blind, people not eligible for Social
Security/Payments not restricted to healthcare costs)
 Can use for extended health care
(Berman et al.)
Financing Health Care
State Children’s Health Insurance Program (SCHIP)
 Insurance coverage for poor & working-class children
 Expands coverage for children under Medicaid
 Subsidizes low-cost state insurance alternatives
 State eligible requirements vary: Children under 18
years of age & family earnings less than $34,100/year
(Berman et al., pp.112-113)
Financing Health Care
Prospective Payment System
 Legislation limits amount paid to a hospital reimbursed by
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Medicare
Reimbursements according to classification system diagnosisrelated groups (DRGs)
Hospital paid predetermined amount for clients with specific
diagnosis
Example: Hospital admits client with diagnosis of
uncomplicated asthma is reimbursed a specific amount,
regardless cost of services, length of stay, or acuity or
complexity of client’s illness
Prospective payment or billing is formulated before client is
even admitted to hospital (Berman et al.. p. 113)
Financing Health Care
Insurance Plans
 Private Insurance--Pays either entire bill or % of costs
 Not-for profit & For-profit
Group Plans
 Health Maintenance Organization (HMO)
 Provides health maintenance & treatment services to
voluntary enrollees
 Emphasizes wellness: Better health
 Fewer HMO services, greater profit for agency
 Choose own healthcare providers
 If client sees specialist, must have referral from primary care
provider
(Berman et al, p. 113)
Financing Health Care
Preferred Provider Organizations (PPO)
 Group of providers & health care agency (often
hospitals) that provide an insurance company or
employer health services at discounted rates
 Advantages
 Choice of health care providers & services
 Can belong to one or more PPO & choose providers from
those PPOs
 Disadvantage
 May be slightly more expensive
(Berman et al., pp. 113-114)
Financing Health Care
Preferred Provider Arrangements (PPA)
 Similar to PPO
 PPAs can be contracted with individual health care
providers;
 Plan can be limited or unlimited
 Limited PPA restricts client to only preferred provider of
health care
 Unlimited PPA permits use by any health care provider in
the area who accepts contractual agreement of the plan
 More choices in health care providers may mean more
cost to enrollee (Berman et al., p. 114)
Financing Health Care
Independent Practice Associations (IPAs)
 Similar to HMOs & PPOs
 Provides health care in offices/clinics as providers
belonging to PPOs
 Difference from PPOs: Clients pay a fixed
prospective payment to IPA & IPA pays the provider
 Some instances health provider bills IPA for services;
Others, provider receives fixed fee for services given
 End of fiscal year any surplus money is divided
among providers; any loss assumed by IPA
(Berman et al, p. 114)
Financing Health Care
Physician/Hospital Organizations (PHOs)
 Joint ventures between group of private practice physicians & hospitals
(Generally include primary care providers & specialists)
 Combine sources & personnel to provide managed care alternatives &
medical services
 Work with variety of insurers to provide services
Integrated Delivery Systems (IDS)
 Incorporates acute care services, home health care, extended & skilled
care facilities, outpatient services; care throughout lifespan
 Insurers contract with IDS s to provide all required services rather than
insurers contracting with multiple agencies for same services
 Enhances continuity of care & communication between professionals &
various agencies providing managed care
(Berman et al, pp. 114)
Social
Economic
Technological
Political
Influences on Health Care System
Berman, A., Snyder, S.J., Kozier, B., & Erb, G. (2008). Health care delivery systems. In A. Berman, S.J. Snyder, B. Kozier, & G. Erb (Eds.).
Kozier & Erb’s Fundamentals of nursing: Concepts, process, and practice (8th ed.) (pp. 101-116). Upper Saddle River, NJ: Prentice Hall
Factors Affecting Healthcare
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4.
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6.
7.
8.
9.
10.
Economics
Increase in number of elderly population
Advances in technology
Women’s Health Movement
Uneven distribution of services
Demographic changes
Homeless & Poor
Access to health insurance
Affordable Health Care Act (Healthcare Reform Law)
Health Insurance Portability & Accountability Act
(HIPPA) (Berman et al.)
How Do Factors Affect Healthcare?
Economics
$$$$$$$$$$$$$
 Existing facilities/equipment becoming obsolete
 Health care providers/patients want newest & best
 Total population growing with largest oldest, who tend
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to have greater health needs
Recognition that “health is everyone’s right,” more are
seeking assistance in health matters
Increase in relative number of people providing health
care services
Increase in number of uninsured and underinsured
Increase in cost of prescription drugs (Berman et al.)
How Do Factors Affect Healthcare?
Increase Number of Elderly
 Long-term illness, chronic diseases, require special
housing, treatment services, financial support, social
networks, special programs to remain in home
Advances in Technology
 Improved diagnostic procedures & sophisticated
equipment, new antibiotics & medications, surgical
procedures, Laser, Computers (electronic medical
records)
 Need highly specialized & trained personnel
(Berman et al)
How Do Factors Affect Healthcare?
Women’s Health Movement
 Research on women’s health equalizing that of men’s
 Change in health care practices:
 Provision of childbirth services—birthing centers
 Emphasis on psychosocial aspects of women’s health:
Impact of career, delayed childbearing, role of caregiver of
older family member, extended life span (Berman et al.)
How Do Factors Affect Healthcare?
Uneven Distribution of Services
 Uneven distribution of healthcare providers
 Rural clients must drive further for care
 Fragmentation of care, & increased costs
 Increased specialization of healthcare providers
 Client may see 5-30 people during one hospitalization
(Berman et al.)
Factors Affecting Healthcare Delivery
Access to Health Insurance
 Lack of insurance
 Income below or near poverty level
 Low income associated with higher rates of infectious
diseases
 Loss of employment (Insurance through job)
(Berman et al.)
Factors Affecting Healthcare Delivery
Affordable Healthcare Act (Healthcare Reform)
 Changes to health insurance coverage & who can have
access to health insurance
 Emphasis of value of health changing to preventative
strategies
(Berman et al.)
How Do Factors Affect Healthcare?
Demographic Changes
 Increase numbers of single-parent families
 Families headed by women, so need childcare while
working or assistance when child is ill
 Increase in cultural & ethnic diversity—Language –
Communication;
How Do Factors Affect Healthcare?
Homeless & Poor
 Health problems related to conditions where homeless
live, health problems often exacerbated, become
chronic
 Lack convenient or timely transportation to
healthcare facilities for homeless
 Improper nutrition, Lack of social support, Exposure
to the elements, Questionable personal safety,
Inadequate rest & privacy
(Berman et al.)
How Do Factors Affect Healthcare?
Health Insurance Portability and Accountability Act
(HIPAA)
 Protects privacy of individuals by safeguarding
individually identifiable healthcare records
 In clinical healthcare sites/facilities/agencies/clinics
 Ancillary health care providers:
 Pharmacies, Laboratories, Third-party Payers (insurance
companies, Medicare, Medicaid)
(Berman et al.)
Providers of Health Care
Nurses
 Advanced Practice Nurses (Nurse Practitioners, Nurse
Mid-wives, Nurse Anesthetist, Clinical Nurse
Specialists, Certified Nurse Educator)
 Registered Nurses & Licensed Practical Nurses
Unlicensed Assistive Personal (UAP)
 Nursing Assistants, Dental Assistants, Home Health
Aides, Personal Care Attendants
Case Manager: Ensure clients receive fiscally sound,
appropriate care in the best setting
 Nurse, Social Worker, Physical Therapists, or other
healthcare team members
Providers of Health Care
Alternative (Complementary) Care Provider
 Chiropractors, herbalists, acupuncturists, massage
therapists, reflexologists, holistic health healers
Physical, Occupational, & Respiratory Therapists
Physician
Physician Assistants-work under physician
Hospitalist
Psychiatrist
Podiatrist
Providers of Health Care
Dentist
Dental Hygienist
Dental Assistant
Dietitian
Paramedical Technologist
Pharmacist
Social Worker
Spiritual Support Personnel
 Chaplains, Pastors, Rabbis, Priests, & other religious
advisors
What is an organizational structure?
Why is it important?
Organizational Charts
What is an organizational structure?
Organizational
structure refers to:
 The way in which a group
is formed
 Its lines of communication
 Its means for channeling
authority & making
decisions
 Consists of activities such as
task allocation,
coordination & supervision,
which are directed towards
the achievement of
organizational aims;
 It means who does what,
who supervises whom, and
who does one report to.
(Organizational Structure of Nursing
Service Department, n.d.)
Types of Organizational Structures
 Formal
 Describes positions, tasks, responsibilities and
relationships among people in their positions in the
different departments in the organization, and
presented in diagrammatic form called
organizational chart.
 Informal
 Describes the personal and social relationships that do
not appear on the organizational chart.
(Organizational Structure of Nursing Service Department, n.d.)
Informal Organizational Structure
 Helps members to meet their personal objectives &
provides social satisfaction
 It has its own channels of communication, which may
distribute information more broadly & rapidly than
the formal communication system (conversation
among employees)
 Informal type is important to management
 Supervisor is aware of its existence, studies its operating
techniques & uses it to meet the organizational
objectives.
(Organizational Structure of Nursing Service Department, n.d.)
Organizational Chart (Formal)
 Diagram shows the different positions &
departments, & relationships among them
 Chart used to show
 The formal organizational relationships
 Areas of responsibility
 Persons to whom one is accountable
 Channels of communication
(Organizational Structure of Nursing Service Department, n.d.)
Sample of Organizational Chart
Effective Organizational Chart
Effective Organizational Chart
1. Its accurate, clear, simple & updated
2. Shows the chain of command, lines of authority,
responsibility & relationships.
3. All members of department should be notified when
any change occurs.
(Organizational Structure of Nursing Service Department, n.d.)
Advantages of Organizational Chart
 Quick visual illustration of organizational structure
 Shows lines of formal authority, responsibility &
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accountability
Clarifies who supervises whom & to whom one is
responsible
Describes channels of communication
Emphasizes the important aspect of each position
Facilitates management development & training
Used to evaluate strengths & weakness of current
structure
Helps in organizational planning & provides starting
points for planning organizational changes
(Organizational Structure of Nursing Service Department, n.d.)
Disadvantages of
Organizational Charts
 Does not show informal relationships
 Does not show duties or responsibilities
(Organizational Structure of Nursing Service Department, n.d.)
See following slides showing various organizational charts.
Most agencies, facilities, departments, & industry have
organizational charts. Some charts show a general view of
departments & to whom those departments are responsible
& report to.
Charts usually are set from the top executives and include all
employee positions.
State Health Department
Organizational Chart Example
Berman, A., Snyder, S.J., Kozier, B., & Erb, G. (2008). Health care delivery systems. In A. Berman, S.J. Snyder, B. Kozier, & G. Erb (Eds.). Kozier &
Erb’s Fundamentals of nursing: Concepts, process, and practice (8th ed.) (pp. 101-116). Upper Saddle River, NJ: Prentice Hall
State Health Agency Chart
Berman, A., Snyder, S.J., Kozier, B., & Erb, G. (2008). Health care delivery systems. In A. Berman, S.J. Snyder, B. Kozier, & G. Erb (Eds.). Kozier
& Erb’s Fundamentals of nursing: Concepts, process, and practice (8th ed.) (pp. 101-116). Upper Saddle River, NJ: Prentice Hall
US Dept. Health & Human Services
Berman, A., Snyder, S.J., Kozier, B., & Erb, G. (2008). Health care delivery systems. In A. Berman, S.J. Snyder, B. Kozier, & G. Erb (Eds.).
Kozier & Erb’s Fundamentals of nursing: Concepts, process, and practice (8th ed.) (pp. 101-116). Upper Saddle River, NJ: Prentice Hall
Long-Term Organizational Chart
Health & Home Care Agency Chart
What is the “Chain of Command”?
Chain of Command = “Line of Authority” and
responsibility along which orders are passed within
the department, the organization, and between units
(Clavreul)
Every healthcare delivery system has one indeed, nearly every
organization, has a chain of command. In most cases, this
chain of command is delineated with a chart, often referred
to as an organizational chart.
A person who uses the chain of command correctly protects
the himself/herself, the patient, & ultimately the
organization (hospital/clinic/agency) (Clavreul)
Four Steps to Using
Chain of Command
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First, call on the charge person (who can use position to
accelerate a response or get the necessary authorization).
[Some organizations chain of command may vary—
Important to know your organization’s chain of command]
Second, should this fail or if for some reason there is no
charge person available, look to the Unit/Department
head (may be Director of Nursing in hospital). Typically
directors or department leaders hold a 9 to 5 position, yet
they can be asked to intervene at any time should the need
arise. (In other words, you may telephone him/her)
(Clavreul)
Four Steps to Using
Chain of Command
 Third, always move up the “Chain of Command” if you get no
response/action from the person you reported to.
 Example: if the person that you reported to does not respond/act, then
contact the person immediately above & gradually move up the
organizational chart until you get a response/action to the situation.
 Fourth, document. Always use facts about the event & not opinions or
personal judgments of the situation.
 Example: If you are having trouble getting the appropriate authorization
to administer medication or perform a procedure, be sure to note this in
the chart.
 If necessary & appropriate, you can also complete an incident report as
defined by your hospital’s policies & procedures.
 Always rely on the hospital’s policy & procedures regarding appropriate
reporting protocols.
(Clavreul)
Chain of Command
 It is important to utilize the proper chain of command in
dealing with any type of situation. Breaking the chain of
command creates communication, follow-up & other
management problems. Therefore, personnel should utilize
the chain of command in all applicable situations.
 It is best to use common sense & a little cooperation to
easily settle which situations dictate chain of command
communication, & what is necessary to accomplish the task
at hand.
(Clavreul)
Chain of Command Process
Official communications both up & down the chain of
command must not skip any rank.
Any assignment given to any person should pass through
all the appropriate ranks.
Any request, comment, suggestion, complaint, etc.
forwarded up the chain of command must start with
the person’s immediate supervisor.
Example: Communication from a nursing assistant should not
be first to the hospital administrator , but following the
appropriate ranks up the organizational chart/structure(one
by one)
(Clavreul)
References
Berman, A., Snyder, S.J., Kozier, B., & Erb, G. (2008). Health care
delivery systems. In A. Berman, S.J. Snyder, B. Kozier, & G. Erb
(Eds.). Kozier & Erb’s Fundamentals of nursing: Concepts,
process, and practice (8th ed.) (pp. 101-116). Upper Saddle River,
NJ: Prentice Hall
Clavreul, G.M. (2011). The nursing chain of command.
WorkingNurse.com. Retrieved from
http://www.workingnurse.com/articles/The-Nursing-Chain-ofCommand
The organizational structure of nursing service department. (n.d.).
Retrieved from
http://faculty.ksu.edu.sa/Hanan_Alkorashy/Nursing%20manage
ment%20489NUR/8._The_organizational_structure_of_nursing
_service_department.pdf