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Chapter 1: Health Care Delivery Systems Feipei Lai National Taiwan University

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  1. Chapter 1: Health Care Delivery SystemsFeipei LaiNational Taiwan University

  2. Health Care Delivery Systems • History of Medicine and Health care Delivery • Continuum of Care • Health Care Facility Ownership • Health Care Facility Organizational Structure • Licensure, Regulation, and Accreditation

  3. Introduction • Health care delivery has been greatly impacted by escalating costs, resulting in medical necessity requirements, review of appropriateness of admissions, and requirement for administration of quality and effective treatments.

  4. On-Line Medical Dictionary • http://cancerweb.ncl.ac.uk/omd/

  5. MRXO • 在臨床醫學中,進行手術時同時使用磁振造影並整合各種影像技術是目前最熱門的醫療概念。新式的「未來手術室」中,安裝有全球首套MRXO解決方案,即完全整合磁振造影(MR)、X光及電腦斷層掃描(CT)系統,大幅減少病患危險並簡化醫師的手續,可望提高手術成功率。 • 這項由日本東海大學、飛利浦醫療系統事業部合力推動的「未來手術室」,已經由日本東海大學的松前教授、津具醫師、山本醫師共同在手術室同時使用MR(磁振造影)和X光影像技術,來進行神經外科手術。

  6. MRXO • 在「未來手術室」中執行手術,可依執刀醫師與病患狀況,在數分鐘內將病患從手術台搬移到磁振造影、電腦斷層掃描或X光診斷系統,增加手術精密度與成功率。在磁振造影和電腦斷層掃描區域有拉門。

  7. PAT: preadmission testing

  8. History of Medicine & Health Care Delivery • History of medicine • Evolution of health care delivery in the United States

  9. History of medicine • Ancient Chinese developed traditional medical practices based on the belief that two life forces, yin and yang, flow through the human body. • Disease results when the two forces are out of balance, and the Chinese use acupuncture (inserting needles into parts of the body) to control the flow of yin and yang.

  10. History of medicine • In 1981, Acquired Immune Deficiency Syndrome (AIDS) and the Human Immunodeficiency Virus III (HIV) were identified. • In 1990, the Human Genome Project was established. In 2000, human genome sequencing was published.

  11. History of medicine • In 1994, scientists discovered the genes responsible for many cases of hereditary colon cancer, inherited breast cancer, and the most common type of kidney cancer.

  12. HW • History of Medicine in Taiwan

  13. Evolution of health care delivery in the United States • 1946 The Communicable Disease Center (CDC) was established and is the forerunner of the Centers for Disease Control and Prevention. • 1971 The National Cancer Act was signed into law, which amended the Public Health Service act to more effectively carry out the national effort against cancer.

  14. Evolution of health care delivery in the United States • 1991 The Workgroup on Electronic Data Interchange (WEDI) was created to reduce health care administrative costs through implementation of the electronic data interchange (EDI), which uses national standards to transmit data for reimbursement purposes.

  15. Evolution of health care delivery in the United States • 1996 The Health Insurance Portability and Accountability Act (HIPAA) was passed. • It mandates administrative simplification regulations that govern privacy, security, and electronic transaction standards for health care information.

  16. Evolution of health care delivery in the United States • 1996 The Healthcare Integrity and Protection Data Bank (HIPDB) was created which combats fraud and abuse in health insurance and health care delivery by alerting users to conduct a comprehensive review of a practitioner’s, provider’s, or supplier’s past actions.

  17. Healthcare Integrity and Protection Data Bank • Access to information in the HIPDB is available to entities that meet the eligibility requirements defined in Section 1128E of the Social Security Act and the HIPDB regulations. In order to access information, eligible entities must first register with the Data Bank. • HIPDB information is not available to the general public. However, information in a form that does not identify any particular entity or practitioner is available.

  18. Healthcare Integrity and Protection Data Bank • http://www.npdb-hipdb.hrsa.gov/ • Estimates of annual losses due to health care fraud range from 3 to 10percent of all health care expenditures--between $30billion and $100billion based on estimated 1997 expenditures of over $1 trillion.

  19. Continuum of Care • A complete range of programs and services is called a continuum of care, with the type of health care indicating the health care services provided. • Primary care • Secondary care • Tertiary care

  20. Primary care services • Include preventive and acute care, are referred to as the point of first care, and are provided by a general practitioner or other health professional who has the first contact with a patient seeking medical treatment, including general dental, ophthalmic 眼科的, and pharmaceutical services.

  21. Primary care services • Annual physical examinations • Early detection of disease • Family planning • Health education • Immunizations • Treatment of minor illnesses and injuries • Vision and hearing screening

  22. Secondary care services • Provided by medical specialists or hospital staff members to a patient whose primary care was provided by a general practitioner who first diagnosed or treated the patient.

  23. Tertiary care services • Provided by specialized hospitals equipped with diagnostic and treatment facilities not generally available at hospitals other than primary teaching hospital or Level I, II, III or IV trauma centers.

  24. Trauma centers • Level I: provides the highest level of comprehensive care for severely injured adult and pediatric patients with complex, multi-system trauma. • Level II: broad range of sub-specialists are on-call and promptly available to provide consultation or care.

  25. Trauma centers • Level III: physicians are advanced trauma life support (ATLS) trained and experienced in caring for traumatically injured patients; nurses and ancillary staff are in-house and immediately available to initiate resuscitative measures.

  26. Trauma centers • Level IV: critically injured patients who require specialty care are transferred to a higher level trauma system hospital in accordance with pre-established criteria.

  27. Tertiary care • Burn center treatment • Cardiothoracic and vascular surgery • Inpatient care for AIDS patients • Magnetic resonance imaging (MRI) • Neonatology level III unit services • Neurosurgery • Organ transplant

  28. Tertiary care • Pediatric surgery • Positron emissions tomography (PET) • Radiation oncology • Services provided to a person with a high-risk pregnancy • Services provided to a person with cancer • State-designated trauma centers • Trauma surgery

  29. Positron emissions tomography (PET) • builds images by detecting energy given off by decaying radioactive isotopes. • Isotopes are atoms of an element with the same number of protons (positively charged particles) in the nucleus, but a different number of neutrons (neutral particles). • Because radioactive isotopes are unstable, as they decay, they throw off positrons that collide with electrons and produce gamma rays that shoot off in nearly opposite directions.

  30. PET http://www.doemedicalsciences.org/abt/sidebars/pet.shtml • PET systems use the paths of the two detected gamma rays to determine the originating collision point, a process called electronic collimation (瞄準). • The scanners use a circular series of gamma ray-detectors to envelope the patient or test animal so both gammas can be detected so the instrument can use electronic collimation to predict where the energy signal originated. • This signal is then converted into a three-dimensional image slice.

  31. http://www.healthvault.com/ • The Microsoft HealthVault record you create is controlled by you. • You decide what goes into your HealthVault record. • You decide who can see and use your information on a case-by-case basis. • We do not use your health information for commercial purposes unless we ask and you clearly tell us we may.

  32. 台灣醫院分類 • 診所 • 地區醫院 (497/2005) • 區域醫院 (80/2005, 65/2006, 64/2007) • 醫學中心 (23/2005, 18/2006, 19/2007)

  33. 醫學中心 • 在衛生局登記開放的急性一般病床與急性精神病床合計須達五百床以上 • 至少應能提供 家庭醫學、內、外、婦產、兒、骨、神經外、泌尿、耳鼻喉、眼、皮膚、神經、精神、復健、麻醉、放射線、病理、核醫、牙 等十九科之診療服務。

  34. 醫學中心 • 專任主治醫師人數 (包括主任在內) 每八床應有一名。 • 專任護理人員每2床至少1名。 • 加護病房:每床2.5名。 • 手術室:每班每台2.5名。 • 手術恢復室:每班每床0.5名。 • 產房及待產室:每床2名。 • 嬰兒室:每床0.4名。 • 急診室:觀察室每床0.5名; • 診療室每12人次1名。 • 門診:每班每診療室0.5名。 • 血液透析室:每4人次1名。 • 行政、教學、研究及其他護理人員 (如院內感染控制、公衛、供應中心等護理人員) 另計,應佔總人數百分之六。 • 應有受過感染控制訓練之專任護理人員,每300床應設1名。

  35. 醫學中心 • 藥事人員每40床至少1名。 • 每60張門診處方至少1名。 • 特殊藥品處方每15張至少1名。 • 藥事人員總數至少四分之三為藥師。 • 藥事人員至少有4名負責藥品管理諮詢及臨床等工作。

  36. 區域醫院 • 應設置250床位以上急性病病床數 • 每床所擁有的樓地板面積應在50平方公尺以上 • 每9床至少應擁有一名主治醫師 • 每2.5床至少應擁有一名護理人員等。 • 至少應能提供 家庭醫學、內、外、婦產、兒、骨、耳鼻喉、眼、精神、復健、麻醉、放射線、病理、牙 等十四科之診療服務。

  37. 區域醫院 Nurse • 加護病房:每床2名。 • 手術室:每班每台2名。 • 手術恢復室:每班每床0.5名。 • 產房及待產室:每床1.2名。 • 嬰兒室:每床0.4名。 • 急診室:觀察室每床0.5名; • 診療室每12人次1名。 • 門診:每班每診療室0.5名。 • 血液透析室:每4人次1名。 • 行政、教學、研究及其他護理人員 (如院內感染控制、公衛、供應中心等護理人員) 另計,應佔總人數百分之四。 • 應有受過感染控制訓練之專任護理人員,每300床應設1名。

  38. 區域醫院 • 藥事人員每50床至少1名。 • 每70張門診處方至少1名。 • 特殊藥品處方每15張至少1名。 • 藥事人員總數至少四分之三為藥師。 • 藥事人員中,至少有2名負責藥品管理諮詢及臨床等工作。

  39. 地區醫院 • 在衛生局登記開放的急性一般病床需20床以上, • 急性一般病床及急性精神病床合計249床(含)以下。

  40. 地區醫院 • 專任員工總人數每床應有1名。 • 專任主治醫師人數以及專任護理人員應符合醫療機構設置標準。 • 藥事人員每50床至少1名。 • 每80張門診處方至少1名。 • 每增加100張處方應增加1名。 • 應有藥師1人以上。

  41. 評鑑分級 • 設施 • 總樓地板面積 • 病房設施 • 安全設備及一般設備 • 保險病床比率

  42. 評鑑分級 • 人員 • 員工總人數 醫師總數 • 麻醉科醫師 放射線科醫師 • 核醫科醫師 病理科醫師 • 復健科醫師 精神科醫師 • 護理 藥事 • 醫事檢驗 醫用放射線技術 • 復健技術 精神科 • 社會工作 營養師 • 病歷管理

  43. 評鑑分級 • 醫療業務及設備 • 醫療業務 急性病床數 • 診療科別 急診業務 • 手術及麻醉作業 產房 • 嬰兒室 加護病房 • 藥事作業 檢驗作業 • 輸血作業 放射線診療作業 • 病理作業 復健醫療作業 • 精神科 核子醫學 • 牙科 特殊醫療服務 • 醫務社會服務工作 營養部門 • 病歷部門 社區衛生服務 • 員工健康檢查

  44. 評鑑分級 • 品質保證 • 醫療品質審查 • 感染控制 • 人體試驗 • 藥事作業品質 • 護理服務品質 • 檢驗作業品質管制 • 輸血作業品質管制 • 病理作業品質管制 • 放射線診療品質管制 • 核子醫學品質管制 • 病歷管理 • 醫院管理業務 • 醫病關係之促進

  45. 評鑑分級 • 指定項目評估 • 住院 • 診斷 • 處置 • 用藥 • 手術 • 病歷寫作

  46. 評鑑分級 • 教學訓練 • 教學師資 • 教學訓練與研究設備 • 教學訓練活動 • 與其他醫院(醫學院)交流合作情形 • 研究情形及論文發表 • 教學進修研究經費

  47. 新制教學醫院評鑑基準 • 教學資源 • 教學訓練計畫與成果 • 研究執行與成果 • 臨床師資培育及繼續教育 • 學術交流與社區功能及角色 • 管理行政

  48. http://www.tjcha.org.tw/Identify.asp?catid=23

  49. Health Care Facility Ownership • Government (not-for-profit) 25% • Proprietary (for-profit) 15% • Voluntary (not-for-profit) 60%

  50. Medical Staff • Intern: a physician in the first year of graduate medical education, which ordinarily immediately follows completion of the four-year medical curriculum. • Resident: a physician who has completed an internship and is engaged in a program of training designed to increase his or her knowledge of the clinical disciplines of medicine, surgery, or any of the other special fields that provide advanced training in preparation for the practice of a specialty.