Putting Patients First: Transforming Tertiary Care Services in Serbia

1. Republic of Serbia MINISTRY OF HEALTH • Putting patient at the heart of change- • the challenge in transitional countries • Katrava A, • Jekić I.M,Obrovački M,Milojković A, Andrejević V, • Đukić V*, Peško P*, Dmitrović T*, Drašković D** Dujmović F**, Trenkić S***,Pavlović R**** • EAR/EU SOFRECO Technical Assistance-TA Team, Belgrade • * Clinical Centre of Serbia, Belgrade • ** Clinical Centre of Vojvodina, Novi Sad • *** Clincal Centre of Niš • **** Clinical Centre of Kragujevac TA for Capacity Building for Tertiary Care Services An EU-funded project managed by the European Agency for Reconstruction

2. In ancient Greece, Hippocrates taught medicine to his students in the spreading shade of a great plane tree. He taught that patients should be the focus of care and that the environment was important factor in healing. TA for Capacity Building for Tertiary Care Services An EU-funded project managed by the European Agency for Reconstruction

3. “Doctor knows best” Back to Basics with IT and patient-centred care: Kaiser L.: Designer Healthcare for a DesignerNation: A New Paradigm TA for Capacity Building for Tertiary Care Services An EU-funded project managed by the European Agency for Reconstruction

4. Context • The EU/EAR Projectprovided to the Ministry of Health-MoH has been charged with • reforming tertiary care services and • implementing an EIB loan of EUR 200M in the beneficiary institutions: the four Clinical Centres in Belgrade, Novi Sad, Nis and Kragujevac for their rehabilitation and strategic development. TA for Capacity Building for Tertiary Care Services An EU-funded project managed by the European Agency for Reconstruction

5. Context • The essence of the EU/EAR Project is to promote the patient at the center of care. • This has been accomplished at an institution level by creating Business Planning Work Groups-WG around main patient flows • Emergency • Outpatient • Inpatient • Day Surgery/Care • Operating Rooms and ICUs TA for Capacity Building for Tertiary Care Services An EU-funded project managed by the European Agency for Reconstruction

6. Context • Corporate services • Health services Management • (non-clinical services) Quality Shared services (clinical support) Clinical services Inpatients Lab. Kitchen Clinical services OPD MED SURG Patient centred care units Imaging/Rad. ICU Finance Laundry OR’S MIS/HIS Purchasing ER DM / DS Med/Surg supplies Tech. services Medical records Pharmacy Sterilization HR Legal Planning TA for Capacity Building for Tertiary Care Services An EU-funded project managed by the European Agency for Reconstruction

7. Background Health care U.S. business invest in: • highly trained human beings • high technology processes and U.S. industry organizes itself around • informatics • just-in-time inventory control ? • Team = Hospital + doctor • Decisions making 24 hours a day (just-in-time) • Reviewing the timetable of care (just-in-time) • Healthcare organization reaches outside the hospital Whitcomb,John E. and Shafa,Mehrdad, Physician executive,Sep/Oct2001,Vol. 27 Issue 5,p16 TA for Capacity Building for Tertiary Care Services An EU-funded project managed by the European Agency for Reconstruction

8. Background - Leadership history • Decision making • Patient care Centralized and Hierarchical Decentralized Clinical governance Direct nursing(in USA since 1966) Patient-centered care (in USA since 1990, in UK since 2000) Framework for improvements through NHS Moiden, Nadeen,Evolution of leadership in nursing,Nursing Management – UK,Nov2002,Vol.9,Issue7 p20 TA for Capacity Building for Tertiary Care Services An EU-funded project managed by the European Agency for Reconstruction

9. Background – CCM vs. EBM • CULTURAL COMPETENCE(CCM) • STRONGER MULTICULTURAL ENVIROMENT LEADS TO IMPROVED COMUNICATIONS WITH PATIENTS MORE BASED ON EVIDENCE BASED MEDICINE (EBM) • MONOCULTURAL CLOSED ENVIRONMENT HAS LESS FLEXIBLE COMUNICATIONS I.E. LESS EBM Hasnain-Wynia, Romana, Is Evidence –Based Medicine Patient Centered and Is Patient –centered Care Evidence-Based? Health Service Research, Feb2006,vol.41,Issue 1 TA for Capacity Building for Tertiary Care Services An EU-funded project managed by the European Agency for Reconstruction

10. Background • In Southeastern Europe countries in transition, health systems are mainly physician-centered and gradually moving to patient-centered care. • This is a long and cumbersome process mainly due to • tradition that clearly sets the dividing line of patients and professionals • in many instances patients are not fully ready to be an active partner in the process • As market forces are introduced into health care services • “choice and competition” will be the better answer than • “command and control” giving patients a right to decide where to be treated. TA for Capacity Building for Tertiary Care Services An EU-funded project managed by the European Agency for Reconstruction

11. Methods • The Clinical Centres have already embarked on the Business Planning process. • Continuing to develop excellence and set the standard for patient-centered care in Serbia will require further evolution along four dimensions; • Measurement • Identify and manage against performance-based measures of service and outcome • Interdepartmental Cooperation • Eliminate barriers between departments that hinder the delivery of care and services; enhance statistical process control skills to identify significant opportunities • Management Skills • Reward “taking risks” to improve service/outcomes • Reporting • Develop status reports and information systems to support the management of quality improvement TA for Capacity Building for Tertiary Care Services An EU-funded project managed by the European Agency for Reconstruction

12. Results • At a system level, Project is facilitating collaboration • vertically between network partners • in primary health care (including first aid) • secondary and tertiary care (other providers) • horizontally with all key stakeholders including • Ministry of Health - MoH • the Institute for Public Health - IPH • National Health Insurance Fund - HIF • Govt’ Agencies • between Clinical Centres. TA for Capacity Building for Tertiary Care Services An EU-funded project managed by the European Agency for Reconstruction

13. Results • At institutional level, four Clinical Centres • due to their central regional/national role and magnitude • could provide a forum for practical application and implementation of a patient-centered care model. • Pilot projects with primary HC, HIF and patient associations are underway. TA for Capacity Building for Tertiary Care Services An EU-funded project managed by the European Agency for Reconstruction

14. Results • The Work Groups-WG consistently supported CC’ service focus on the needs of the patient and family. • Seven (out of 28) strategic recommendations emerged in CC’s 5-year Business Plan: • Patients and their families need to participate actively in the care process (1-3) • Each patient's care will be coordinated, in Clinical Center and across the network (4-5) • The setting will foster the well-being of the patient and family (6-7) TA for Capacity Building for Tertiary Care Services An EU-funded project managed by the European Agency for Reconstruction

15. ResultsSeven (out of 28) strategic recommendations emerged in CC’s 5-year Business Plan: To ensure that patients and their families are able to participate actively in the care process, WE RECOMMEND THAT: • (1) The Clinical Centers should adapt its services to the individual patient's and family's situation. In particular, services should: • ensure that all staff develop approaches and interventions that respond to the needs and situation of the patient and family • ensure that dedicated resources are available to support the psycho-social and ethical needs of the patient and family • disrupt as little as possible the patient's normal work, school or other activities by offering flexible, extended hours and providing care closer to patients at satellite clinics, whenever possible • respect patients' their spiritual, religious needs and cultural traditions • (2) The Clinical Centers should establish procedures that ensure that patients are provided with appropriate information about their care, and that they receive every opportunity to take an active part in decision-making related to their care. The Clinical Centers should give patients, in their homes, access to information related to their treatment as soon as possible, using currently available technology. • (3) The Clinical Centers should ensure that each patient has a personal care plan, developed by a team that includes the patient and family, and, when appropriate, shared with other health care providers involved in the treatment of the patient across the network, using Information Technology, where available. To ensure that each patient's care is coordinated, both within the Clinical Centers and across the network, WE RECOMMEND THAT: • (4) The Clinical Centers should further define, develop, and emphasize patient care coordination across all programs of care, including: • educating patients, Clinical Center staff, and the community about how patient care coordination works for them • providing training for the patient care coordination function • establishing mechanisms to evaluate the impact of care coordination on patient care • (5) The Clinical Centers should further develop and enhance information systems that support and improve coordination of care, including: • scheduling systems • complete electronic health records • internal electronic communications systems • telecommunications links with community-based professionals To ensure that the setting of the Clinical Centers will foster the well-being of the patient and family, WE RECOMMEND THAT: • (6) The design of the (re-)developed Clinical Centers should create a healing environment that is flexible in conception, based on the most recent research into the positive effects of lighting, ventilation, sounds, natural elements, textures and finishes, and other architectural and design features on patient care outcomes. The environment should be planned to alleviate stress in patients and their families, staff, and others who work in the facility. • (7) Patient rooms in the Clinical Centers should be designed to accommodate the presence of family members, where appropriate. Adequate space for families should be provided, including a common meeting room that can be also used for other meeting purposes. TA for Capacity Building for Tertiary Care Services An EU-funded project managed by the European Agency for Reconstruction

16. Results • Flows • for Emergency • for Inpatient • for Outpatients have been developed by responsible WG in all CC’s • data survey results • Jointly, both represent basis to make operational improvements in particular patient flow areas putting them at the centre of care. TA for Capacity Building for Tertiary Care Services An EU-funded project managed by the European Agency for Reconstruction

17. Conclusions • Patient centered care culture in transitional country could be introduced and developed by • Observing cultural competence – CCM • Promoting evidence-based medicine – EBM To link Natural tendency of careers to care and Knowledge of how that should be done in contemporary medicine / health care TA for Capacity Building for Tertiary Care Services An EU-funded project managed by the European Agency for Reconstruction