Hospital Reform Research Articles

Regionalization and Health Networks.

The aim of this article was to reflect on the challenges faced in building the Health Regions and Networks in Brazil. These reflections result from studies conducted in several health regions. The central challenges for the constitution of the Health Regions and Networks are as follows: the Care Model, Primary Health Care, Care for Users with Chronic Diseases, and Hospital Care. In order to consolidate the regions and networks the organization needs to incorporate an ethical sense: focusing on social, public and individual needs, derived from comprehensive care, human and social rights, in broad, multi-scale and inter-sectorial interactions, with the constitution of a systemic, regionalized innovation. Of prime importance is the capacity to devise which general principles are responsible for maintaining the unity(mode of care), seeking to outline the coherence of the different provision models that the system might develop according to the social needs in regional settings. Without that, users will continue to seek and create ways of accessing health services that challenge the rationale of those very services. Hospital reform is also required to integrate and reorient the hospital networks. These reflections are important for the SUS to uphold its solidarity project, expressed in the trinity of universality-comprehensiveness-equality.

Die deutsche Krankenhauspolitik: Eine Geschichte verpasster Strukturreformen?

Abstract:The introduction of the DRG system in 2003/04 can be considered the last real hospital reform. Although the latest reform was called Hospital Structure Act due to its insufficient structural components it is sometimes referred to as missed reform. Essential aspects of the institutional background remained unchanged. However, a closer look reveals even the introduction of the DRG system was only a change in the reimbursement of operating costs. Further structural changes were neither discussed nor induced. The same applies to all subsequent reforms. The key parameters of the regulatory framework are for the greater part the same as those established by the German Hospital Finance Act in 1972. Against this backdrop, the presented paper discusses the institutional background and potential reasons for its continuance. The focus is on the question, whether missed reforms are based on its optimality or which alternative explanations seem to be convincing.

Effects of County Public Hospital Reform on Procurement Costs and Volume of Antibiotics: A Quasi-Natural Experiment in Hubei Province, China.

BackgroundThe overuse of antibiotics has become a major public health challenge worldwide, especially in low- and middle-income countries, including China. In 2009, the Chinese government launched a series of measures to de-incentivise over-prescription in public health facilities, including decoupling the link between facility income and the sale of medicines.ObjectivesWe evaluated the effects of these measures on procurement costs and the volume of antibiotics in county public hospitals.MethodsThe study was undertaken in the Hubei province of China, where 64 county public hospitals implemented the reform in sequence at three different stages. A quasi-natural experiment design was employed. We performed generalised linear regressions with a difference-in-differences approach using 22,713 procurement records of antibiotics from November 2014 to December 2016.ResultsThe regression results showed that the reform contributed to a 14.79% increase in total costs for antibiotics (p = 0.013), particularly costs for injectable antibiotics (p = 0.022) and first-line antibiotics (p = 0.030). The procurement prices for antibiotics remained largely comparable to those in the control group, but the reform led to a 17.30% increase in the procurement volume (expressed as defined daily doses) of second-line antibiotics (p = 0.032).ConclusionsCounty public hospitals procured more antibiotics and greater numbers of expensive antibiotics, such as those administered via injection, to compensate for the loss of income from the sale of medicines, leading to an increased total cost of antibiotics.Electronic supplementary materialThe online version of this article (10.1007/s40273-018-0654-1) contains supplementary material, which is available to authorized users.

Diagnosis-related group (DRG)-based case-mix funding system, a promising alternative for fee for service payment in China.

Fee for services (FFS) is the prevailing method of payment in most Chinese public hospitals. Under this retrospective payment system, medical care providers are paid based on medical services and tend to over-treat to maximize their income, thereby contributing to rising medical costs and uncontrollable health expenditures to a large extent. Payment reform needs to be promptly implemented to move to a prospective payment plan. The diagnosis-related group (DRG)-based case-mix payment system, with its superior efficiency and containment of costs, has garnered increased attention and it represents a promising alternative. This article briefly describes the DRG-based case-mix payment system, it comparatively analyzes differences between FFS and case-mix funding systems, and it describes the implementation of DRGs in China. China's social and economic conditions differ across regions, so establishment of a national payment standard will take time and involve difficulties. No single method of provider payment is perfect. Measures to monitor and minimize the negative ethical implications and unintended effects of a DRG-based case-mix payment system are essential to ensuring the lasting social benefits of payment reform in Chinese public hospitals.

Balanced scorecard-based performance evaluation of Chinese county hospitals in underdeveloped areas.

ObjectiveSince the Guangxi government implemented public county hospital reform in 2009, there have been no studies of county hospitals in this underdeveloped area of China. This study aimed to establish an evaluation indicator system for Guangxi county hospitals and to generate recommendations for hospital development and policymaking.MethodsA performance evaluation indicator system was developed based on balanced scorecard theory. Opinions were elicited from 25 experts from administrative units, universities and hospitals and the Delphi method was used to modify the performance indicators. The indicator system and the Topsis method were used to evaluate the performance of five county hospitals randomly selected from the same batch of 2015 Guangxi reform pilots.ResultsThere were 4 first-level indicators, 9 second-level indicators and 36 third-level indicators in the final performance evaluation indicator system that showed good consistency, validity and reliability. The performance rank of the hospitals was B > E > A > C > D.ConclusionsThe performance evaluation indicator system established using the balanced scorecard is practical and scientific. Analysis of the results based on this indicator system identified several factors affecting hospital performance, such as resource utilisation efficiency, medical service price, personnel structure and doctor–patient relationships.

What do patients care most about in China\u2019s public hospitals? Interviews with patients in Jiangsu Province

BackgroundEvaluations on different aspects of the performance of public hospitals in China have been conducted, usually based on indicators developed by literature review and expert suggestions. The patient perspective was not always considered. This study aims to identify what patients care most about in China’s public hospitals exclusively from a patient perspective.MethodsA mix of stratified sampling and typical sampling was used to select 15 public hospitals in Jiangsu Province of China. In each sampled hospital, a convenient sample of six outpatients and six inpatients was selected to conduct face-to-face individual interviews. An interview guide consisting of six open-ended questions was designed. Donabedian’s quality of care framework was applied to categorize themes and subthemes, which were generated from patients’ interviews by using the conventional content analysis approach. Frequencies of themes and subthemes were counted.ResultsNine key themes were identified regarding patients’ concerns about hospital care, which were environment and facilities, professional competence, hospital reputation, and morals of medical staff in the “structure” category of Donabedian’s framework, caring attitudes and emotional support, medical costs, communication and information, and efficiency and coordination of care in the “process” category, and health outcomes in the “outcome” category.ConclusionsThis study has identified and prioritized the aspects that patients care most about in China’s public hospitals in Jiangsu Province exclusively from a patient perspective. A measurement tool of patient-reported experiences in public hospitals could be built based on this study. Efforts should be made to represent the patient perspective to further improve the reform of public hospitals in China.

Hospital efficiency and utilization of high-technology medical equipment: A panel data analysis

ObjectiveThe association between hospital characteristics and utilization of high-tech medical equipment has received more attention for its complicated consequences on health care costs and quality. This study aims to take a step further by focusing on the relationship between hospital efficiency and utilization of Computed Tomography (CT) and Magnetic Resonance Imaging (MRI). MethodsWe selected a random sample of 131 hospitals, and conducted a questionnaire survey in each of the sampled hospitals in 2009–2013. We first estimated hospital cost inefficiency scores through stochastic frontier analysis. Then, we examined how the scores as well as population, GDP, hospital volume, annual number of surgical cases and hospital beds were associated with CT and MRI utilization rates through a series of linear regression models with hospital-level fixed effect. We also conducted a series of sensitivity checks to estimate the inefficiency scores or applying different time-lags to the scores in the regression models. ResultsThe descriptive and regression analysis revealed a positive and significant association between the scores and CT (P< 0.01) or MRI (P< 0.05) utilization rate. Regarding other covariates, hospital volume, annual number of surgical cases were significantly associated with CT (P< 0.05), not MRI (P> 0.05) utilization rate. The sensitivity checks confirmed the robustness of the results. ConclusionsUtilization of CT and MRI increased with hospital cost inefficiency. The finding has important policy implication for the ongoing hospital reform in China.

Misconception concerning Florence Nightingale and Critical Care Medicine

Background: Florence Nightingale OM, a remarkable pioneer in nursing practice and education, in reform of hospital and health practices, in application of statistical methods, etc., etc., generally holds a very high place in medical esteem – and this writer's. On multiple recent occasions ‘Nightingale’ has been acclaimed by authoritative writers in papers on critical care history (CCM) for a vision anticipating practice modes of that modern specialty. They have caused this writer disquiet.

Iran's Struggling Health System: An Increase in Natural Childbirth: A Case Study.

Background:The 7th package of health reform in Iran has been implemented in May 15, 1393, is concerned with the “promotion of natural childbirth.” It has been focusing on reducing cesarean section (CS) and promoting normal vaginal delivery (NVD) as broadly as possible. This study evaluated the changes in the vaginal delivery and cesarean before and after implementation of the 7th package of health reform in public and private hospitals of Isfahan Province in 2014.Methods:This was a quasi-experimental research. The population of this study contained all public and private hospitals in Isfahan Province covered by the Health Reform Program. It included 22 public and 6 private hospitals. The data collected from the vice chancellor of treatment in 6 months before and after the implementation of the program have been analyzed. SPSS software version 18.0 (SPSS Inc., Chicago, IL, USA) and independent t-test have been employed for data analysis.Results:It was demonstrated that the increasing rate of NVD (P = 0.001) and decreasing rate of CS in public hospitals (P = 0.027) after the implementation of the plan were significant. On the other hand, the increasing rate of CS in private hospitals was significant (P = 0.026).Conclusions:Although this scheme has achieved its targets in public hospitals of Isfahan Province, it has not met its objectives in private hospitals. It seems CS operations were shifted from public hospitals to private ones, which is conflict with the objectives of the health reform plan.

Impacts of the referral system on outpatient satisfaction: an analysis of propensity score analysis

Objective To analyze impacts of the referral system on outpatient satisfaction with the background of developing a hierarchical medical system, and to provide recommendations for further improvements of the referral system. Methods Based on the outpatient satisfaction survey results of the National Healthcare Improvement Initiative Third Party Assessment (2016-2017), the propensity matching method was used to analyze the satisfaction of outpatients who were referred and not referred. Results Compared with the overall satisfaction score of the non-referred outpatients, that of the referred outpatients was 0.11 points lower (P<0.01, 95%CI=-0.17, -0.06). The patient experience satisfaction score of the referred outpatients was 0.06 points lower than that of the non-referred(P=0.03, 95%CI=-0.11, -0.01). Conclusions Under the policy background of the hierarchical medical system in China, the current referral system has failed to positively improve patient satisfaction. To further improve the referral system and to raise patient satisfaction, there is a need to take following actions, to link the referral system construction with the public hospital reforms, in order to motivate the tertiary hospitals to be more actively involved in the strengthening of the referral system, to strengthen the medical capacity of the primary health care institutions, to standardize the referral criteria and procedure, and to formulate a more rational and effective health insurance payment method and reimbursement system. In addition, it is critical to further regulate and optimize the referral procedures, so as to set up reasonable and effective insurance payment and reimbursement for the referred patients, to promote the dissemination and to raise public awareness of the referral policy. Finally, it is necessary to enhance the diagnostic and treatment skills of the primary level of the health care delivery system. Key words: Patient transfer; Hierarchical medical system; Propensity matching method; Outpatients; Satisfaction

Financing improvement process in the hospital management —A case study on Saitama Prefectural hospital reform—

Financing improvement process in the hospital management —A case study on Saitama Prefectural hospital reform—

Rationing nurses: Realities, practicalities, and nursing leadership theories.

In this paper, we examine the practicalities of nurse managers' work. We expose how managers' commitments to transformational leadership are undermined by the rationing practices and informatics of hospital reform underpinned by the ideas of new public management. Using institutional ethnography, we gathered data in a Canadian hospital. We began by interviewing and observing frontline leaders, nurse managers, and expanded our inquiry to include interviews with other nurses, staffing clerks, and administrators whose work intersected with that of nurse managers. We learned how nurse managers' responsibility for staffing is accomplished within tightening budgets and a burgeoning suite of technologies that direct decisions about whether or not there are enough nurses. Our inquiry explicates how technologies organize nurse managers to put aside their professional knowledge. We describe professionally committed nurse leaders attempting to activate transformational leadership and show how their intentions are subsumed within information systems. Seen in light of our analysis, transformational leadership is an idealized concept within which managers' responsibilities are shaped to conform to institutional purposes.

Efficiency and Productivity of County-level Public Hospitals Based on the Data Envelopment Analysis Model and Malmquist Index in Anhui, China.

Background:China began to implement the national medical and health system and public hospital reforms in 2009 and 2012, respectively. Anhui Province is one of the four pilot provinces, and the medical reform measures received wide attention nationwide. The effectiveness of the above reform needs to get attention. This study aimed to master the efficiency and productivity of county-level public hospitals based on the data envelopment analysis (DEA) model and Malmquist index in Anhui, China, and then provide improvement measures for the future hospital development.Methods:We chose 12 country-level hospitals based on geographical distribution and the economic development level in Anhui Province. Relevant data that were collected in the field and then sorted were provided by the administrative departments of the hospitals. DEA models were used to calculate the dynamic efficiency and Malmquist index factors for the 12 institutions.Results:During 2010–2015, the overall average relative service efficiency of 12 county-level public hospitals was 0.926, and the number of hospitals achieved an effective DEA for each year from 2010 to 2015 was 4, 6, 7, 7, 6, and 8, respectively, as measured using DEA. During this same period, the average overall production efficiency was 0.983, and the total productivity factor had declined. The overall production efficiency of five hospitals was >1, and the rest are <1 between 2010 and 2015.Conclusions:In 2010–2015, the relative service efficiency of 12 county-level public hospitals in Anhui Province showed a decreasing trend, and the service efficiency of each hospital changed. In the past 6 years, although some hospitals have been effective, the efficiency of the county-level public hospitals in Anhui Province has not improved significantly, and the total factor productivity has not been effectively improved. County-level public hospitals need to combine their own reality to find their own deficiencies.

Effects on the medical revenue of comprehensive pricing reform in Chinese urban public hospitals after removing drug markups: case of Nanjing

Aims: The State Council of China requires that all urban public hospitals must eliminate drug markups by September 2017, and that hospital drugs must be sold at the purchase price. Nanjing-one of the first provincial capital cities to implement the reform—is studied to evaluate the effects of the comprehensive reform on drug prices in public hospitals, and to explore differential compensation plans.Methods: Sixteen hospitals were selected, and financial data were collected over the 48-month period before the reform and for 12 months after the reform. An analysis was carried out using a simple linear interrupted time series model.Results: The average difference ratio of drug surplus fell 13.39% after the reform, and the drug markups were basically eliminated. Revenue from medical services showed a net growth of 28.25%. The overall compensation received from government financial budget and medical service revenue growth was 103.69% for the loss from policy-permitted 15% markup sales, and 116.48% for the net loss. However, there were large differences in compensation levels at different hospitals, ranging from –21.92% to 413.74% by medical services revenue growth, causing the combined rate of both financial and service compensation to vary from 28.87–413.74%, There was a significant positive correlation between the services compensation rate and the proportion of medical service revenue (p < .001), and the compensation rate increased by 8% for every 1% increase in the proportion of services revenue.Discussion: Nanjing’s pricing and compensation reform has basically achieved the policy targets of eliminating the drug markups, promoting the growth of medical services revenue, and adjusting the structure of medical revenue. However, the growth rate of service revenue of hospitals varied significantly from one another.Conclusions: Nanjing’s reform represents successful pricing and compensation reform in Chinese urban public hospitals. It is recommended that a differentiated and dynamic compensation plan should be established in accordance with the revenue structure of different hospitals.

Empower the scientific research of grass-roots hospital by innovation-driven strategy

Objective To further intensify the reform of public hospitals, promote talents team building and scientific research management innovation, enhancing the overall capacity of care delivery, as well as the development of science and technology in grass-roots hospitals. Methods A series of measures were adopted to arouse the enthusiasm of personnel to conduct research and finally increase the research outcomes. Concrete measures include talent training program and scientific research management innovation, construction funding assurance, whole-process dynamic management, clarification of the quantitative evaluation index, research rewards, research funding management, as well as performance management. Results After implementation of such measures, the academic atmosphere changed a lot, medical technology improved, the quality of scientific research, project application and research outcomes increased dramatically which has statistical significance compare to previous situations. Conclusions The establishment of the incentive system plays a significant role. It helps in talent agglomeration during a relatively short period of time, exploring the potential capabilities of scientific research, enhancing the core competitiveness of hospital scientific research, which provide strong intellectual support and talent guarantee for hospitals development. Key words: Personnel; Scientific research; Innovation-driven; Incentive system; Quantified assessment indexes,

Bootstrapping data envelopment analysis of efficiency and productivity of county public hospitals in Eastern, Central, and Western China after the public hospital reform.

China implemented the public hospital reform in 2012. This study utilized bootstrapping data envelopment analysis (DEA) to evaluate the technical efficiency (TE) and productivity of county public hospitals in Eastern, Central, and Western China after the 2012 public hospital reform. Data from 127 county public hospitals (39, 45, and 43 in Eastern, Central, and Western China, respectively) were collected during 2012-2015. Changes of TE and productivity over time were estimated by bootstrapping DEA and bootstrapping Malmquist. The disparities in TE and productivity among public hospitals in the three regions of China were compared by Kruskal-Wallis H test and Mann-Whitney U test. The average bias-corrected TE values for the four-year period were 0.6442, 0.5785, 0.6099, and 0.6094 in Eastern, Central, and Western China, and the entire country respectively, with average non-technical efficiency, low pure technical efficiency (PTE), and high scale efficiency found. Productivity increased by 8.12%, 0.25%, 12.11%, and 11.58% in China and its three regions during 2012-2015, and such increase in productivity resulted from progressive technological changes by 16.42%, 6.32%, 21.08%, and 21.42%, respectively. The TE and PTE of the county hospitals significantly differed among the three regions of China. Eastern and Western China showed significantly higher TE and PTE than Central China. More than 60% of county public hospitals in China and its three areas operated at decreasing return scales. There was a considerable space for TE improvement in county hospitals in China and its three regions. During 2012-2015, the hospitals experienced progressive productivity; however, the PTE changed adversely. Moreover, Central China continuously achieved a significantly lower efficiency score than Eastern and Western China. Decision makers and administrators in China should identify the causes of the observed inefficiencies and take appropriate measures to increase the efficiency of county public hospitals in the three areas of China, especially in Central China.

Municipal trusteeship of district-launched medical institutions: experiment at Beijing Children′s Hospital

The paper introduced the background and concepts of municipal trusteeship of district-launched medical institutions, with the trusteeship of women and children′s hospital of Shunyi district as an example. In addition to the main approaches and contributions in improving hospital management, delivery of quality medical resources to primary care, and capacity building, the authors called for the support for standardized healthcare, respect for original hospital culture, and sustained government support to the hospital in question among other points, for reference of further public hospital reform. Key words: Beijing Children′s Hospital; Municipal trusteeship of district-launched medical institutions; Trusteeship; Medical collaborations; Standardization

Physician Autonomy and the Paradox of Rationalization

Tools meant to standardize and rationalize clinical practice have been widely used in healthcare institutions. One tool in particular, clinical pathways, has been a key component of the recent public hospital reform in China. Clinical pathways regulate how the core activities of the medical professional should be performed. Examining pathway implementation and physicians’ attitude toward them may shed light on the extent of discretion and autonomy physicians have in their core activities. Therefore, this study takes clinical pathways as a lens through which to study Chinese physicians’ work and autonomy and asks three questions: First, what is the attitude of physicians toward clinical pathways? Second, how are pathways implemented in physicians’ practice? And third, what are the determinants of physicians’ attitude? Both quantitative and qualitative data are used to explore the research questions. The quantitative data come from a survey of 158 physicians in three tertiary hospitals in two provincial capitals. The qualitative data are from all online discussions about clinical pathways on one of the most popular social networking websites for physicians and hospital administrators. The findings are consistent with the prediction based on sociological theorization of rationalization in professional work. Namely, there are two distinct dimensions in physicians’ attitude toward clinical pathways: physicians felt that pathways made their practice more scientific, but they also felt that the pathways were burdensome and restrictive. Physicians were in general heavily involved in the process of pathway implementation, and restrictive monitoring and sanctioning practices were relatively uncommon. Factors associated with pathway implementation were important predictors of physicians’ attitude, whereas professional orientation and concerns with the status of the profession had limited effect. Taken together, the findings from this exploratory study suggest that although physicians in China's public hospitals are dependent on their organizations, they retain considerable discretion in the implementation and use of clinical pathways. On the other hand, physicians’ views of clinical pathways are more prominently shaped by organizational factors than by their professional orientation.

AN ANALYSIS OF HOSPITAL SERVICE USAGE TO INFORM RIGHTSIZING REGIONAL HOSPITALS

The new approach of the hospital development and reform in Romania, from the perspective of the National Health Strategy 2014-2020, focuses especially on the establishment of regional hospitals. The main concern in this process is connected to rightsizing this type of healthcare units, in order to further ensure proper functioning, from the very beginning of the design phase. To get the right number of beds reflected in the regional hospital sizing, we analyzed, starting from the Regional Health Service Plans, the usage of healthcare services across each of the eight administrative regions in Romania. Through this analysis, we intended to find in what way and to which hospital the patients are addressing, as well as the complexity of the hospitalized cases, thus establishing a pattern of usage. The most interesting element of the analysis was patients’ migration to hospitals situated in counties or regions different from those of their residence. Since the number of beds is also a determining factor for staffing as well as for providing a certain volume and type of services, we considered that the pattern of usage is the link between the expressed need for services and the hospital's response capacity. Following the analysis, we made a proposal for rightsizing the regional hospitals, based on one of four calculation variants. Keywords: hospital, healthcare service usage, patient migration, bed occupancy rates, rightsizing, demand forecasting . Normal 0 21 false false false RO X-NONE X-NONE /* Style Definitions */ table.MsoNormalTable {mso-style-name:Table Normal; mso-tstyle-rowband-size:0; mso-tstyle-colband-size:0; mso-style-noshow:yes; mso-style-priority:99; mso-style-parent:; mso-padding-alt:0cm 5.4pt 0cm 5.4pt; mso-para-margin-top:0cm; mso-para-margin-right:0cm; mso-para-margin-bottom:10.0pt; mso-para-margin-left:0cm; line-height:115%; mso-pagination:widow-orphan; font-size:11.0pt; font-family:Calibri,sans-serif; mso-ascii-font-family:Calibri; mso-ascii-theme-font:minor-latin; mso-hansi-font-family:Calibri; mso-hansi-theme-font:minor-latin; mso-bidi-font-family:Times New Roman; mso-bidi-theme-font:minor-bidi; mso-fareast-language:EN-US;}

Qualitative analysis of direction of public hospital reforms in China.

Reforms in public hospitals are among the most important improvements in China's health care system over the last two decades. However, the reforms that should be implemented in public hospitals are unclear. Thus, a feasible direction of reforms in Chinese public hospitals is suggested and reliable policy suggestions are provided for the government to reform public hospitals. The data used in this study were mainly derived from a qualitative study. Focus group discussions and in-depth interviews were conducted in Shanghai, Guangdong, and Gansu between May and December 2014. Government funding accounted for approximately eight percent of the total annual revenue of public hospitals in China, and the insufficient government subsidy considerably affects the operation mechanism of public hospitals. However, solely increasing this subsidy cannot address the inappropriate incentives of public hospitals in China. The most crucial step in setting the direction of reforms in public hospitals in China is transforming inappropriate incentives by implementing a new evaluation index system for directors and physicians in public hospitals.