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Republic of Serbia MINISTRY OF HEALTH. Day Surgery/ Day Hospital : Challenging existing models of service delivery in a transitional country Jeki ć I .M , Katrava A, Boulton G, Milojković A, Andrejevi ć V, Koumpis N,

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slide1

Republic of Serbia

MINISTRY OF HEALTH

  • Day Surgery/ Day Hospital:
  • Challenging existing models of service delivery
  • in a transitional country
  • Jekić I.M,
  • Katrava A, Boulton G, Milojković A,Andrejević V, Koumpis N,
  • 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

context
Context
  • Day Surgery/Day Hospital models of service delivery are in their early stage in Serbia.
  • The health reform targets call for 3-5% annual increase in ambulatory services.
  • 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 Clinical Centres in Belgrade, Novi Sad, Nis and Kragujevac for their rehabilitation and strategic development.
  • Four largest university hospitals in Serbia together have
    • over 220,000 inpatients
    • 120,000 surgeries annually
    • rather low day surgery/day hospital cases rates.

TA for Capacity Building for Tertiary Care Services

An EU-funded project managed by the European Agency for Reconstruction

international surveys country benchmarks for day surgery activity
International surveys – Country benchmarks for day surgery activity

Background

  • International Association for Ambulatory Surgery & OECD
  • Results of World Wide Day Surgery Activity 2003
    • 18 countries or regions, 37 procedures
    • In most countries day surgery activities are within public hospitals (In USA where activity is very high, the percentage of private free standing units is also very high)
    • Reimbursement systems are very different
    • USA, Canada and Scandinavian countries have high percentage of day surgery procedures
    • Countries having high rate of day surgery in some specialties may have significantly low rate in other specialties

TA for Capacity Building for Tertiary Care Services

An EU-funded project managed by the European Agency for Reconstruction

international variations in availability and diffusion of day surgery
International variations in availability and diffusion of day surgery

Background

Micro level

  • Patients or physicians may not want, or may not be able to use day surgery
  • Hospital characteristics, such as the number of hospital beds

Macro level

  • Health care system characteristics, such as financing and insurance influence the shift to day surgery

TA for Capacity Building for Tertiary Care Services

An EU-funded project managed by the European Agency for Reconstruction

key factors to consider as care shifts to day surgery outpatient
Key factors to Consider as Care Shifts to Day Surgery + Outpatient

Background

  • Impact of Competition
  • Private physician offices
  • Cost
  • Increased supply, technology costs
  • Length-of-stay cost savings
  • Payer mix
  • Health Insurance coverage
  • Ancillary Demand
  • Related billable

volume

  • Market Growth
  • Potential
  • Improve Outcomes
  • Reduced risk and pain

TA for Capacity Building for Tertiary Care Services

An EU-funded project managed by the European Agency for Reconstruction

slide6

Background

Slow Pace of Clinical ProliferationTechnology-Driven Outpatient Growth

100%

Percentage

Outpatient

0%

Time

TA for Capacity Building for Tertiary Care Services

An EU-funded project managed by the European Agency for Reconstruction

background trend in take up of day surgery
Background Trend in take up of day surgery

TA for Capacity Building for Tertiary Care Services

An EU-funded project managed by the European Agency for Reconstruction

background
Background
  • Even when the evidence for change to clinical practice is so strong and seemingly self evident, there is no guarantee that it will be adopted.
  • This is a classic management of change issue that involves
    • “soft” factors such as professional attitudes
    • “hard” factors such as data / resources / appropriate funding system from the Health Insurance Fund - HIF as an incentive for this change.
  • Currently, HIF funds the hospital based on a “hospital day” and therefore operating budget disincentives to “shift” to day surgery because the HIF will not reimburse the hospital for a day case.
  • This causes certain deviation/adjustments in recording/invoicing of the day surgery cases towards the HIF, resulting in lower rate of recorded day surgery cases that have really been performed

TA for Capacity Building for Tertiary Care Services

An EU-funded project managed by the European Agency for Reconstruction

methods
Methods
  • Over past seven years, the Clinical Centres have still been operating under
    • unchanged legislation
    • unchanged model of service delivery
    • fixed operating budgets
  • These represents limitation for the hospitals to respond to increasing demands of emerging ambulatory service delivery model.
  • The EU/EAR Project is a vehicle with capital investments providing an opportunity
    • to restructure space for more day surgery and day hospital
    • to facilitate professionals buy-in to this model of service delivery
    • to motivate MoH to support this change due to systemic improvement in quality of care and lowering costs
    • to influence MoH and HIF to change financing models.

TA for Capacity Building for Tertiary Care Services

An EU-funded project managed by the European Agency for Reconstruction

slide10

Methods - Organization of day surgery

  • Accommodation for day surgery
    • Most cost-effective option is a self-contained day surgery unit, with its own admission suite, theatre and recovery area together with administrative facilities.
    • Less satisfactory arrangement is a day case ward with patients going to the main operating room
  • Management of the day surgery unit
    • Day surgery needs a rigorous management structure including
      • lead clinician
      • day surgery manger/senior nurse
      • other staff
  • Changes of working practices
    • Specific training for the surgeon and anesthetist in day surgery techniques
      • Local incentives, such as the availability of enhanced resources to those who shift treatment to day surgery
      • Dedication of theatres for day case are preferred for better output, compared to theatre/ward mix with inpatient surgery
    • The advantages to patients
      • Opportunities to see and experience day surgery

TA for Capacity Building for Tertiary Care Services

An EU-funded project managed by the European Agency for Reconstruction

methods11
Methods

Research within the Clinical Centers

  • Research was conducted as
    • qualitative questionnaire of staff
    • quantitative/qualitative measurement of operating facility utilization
  • Research covered
    • 112 operating theatres
    • over two weeks period
    • analyzing over 3000 surgical interventions
  • Qualitative questionnaire (anonymous) was distributed
    • among top and medium management in all 4 Clinical Centers
    • covering 320 managers of different level

TA for Capacity Building for Tertiary Care Services

An EU-funded project managed by the European Agency for Reconstruction

results
Results
  • It is an internationally accepted standard that 70% of elective surgery cases can be undertaken in day setting.
  • In 2008, specific annual targets for 25 selected procedures that can be done safely and effectively as day cases will be set in a step-wise fashion.
  • Results of the survey
    • There is no formalized day surgery in Serbia for most of procedures
    • There is uneven and non systemic development of day surgery in CC’s
    • There is a different understanding of day surgery definition and procedures between medical employees
    • Still, there is awareness of day surgery importance and willingness to change towards day surgery
    • Survey data shows deviation between recorded and actual day services provided
    • There are no financial incentives for providers to shift to day surgery in spite all other benefits
    • Expected list of procedures for day surgery is very similar with UK basket of 25 procedures

TA for Capacity Building for Tertiary Care Services

An EU-funded project managed by the European Agency for Reconstruction

results13
Results

There is a potential to carry out more day surgery and elective operations within current resources by

redistributing and dedicating theatres

improving scheduling

reducing cancellations

decreasing gaps between patients

improving the management of existing theatre resources.

However

There is no functional scheduling and reporting system for utilization

There is no theatre/ward booking system prior to admission of patients;

There is no measurement of utilization of operating facilities;

Members of OR teams are not fully trained for day surgery work flow

Still

There is evidenced increase in day surgery in Serbia from 2002.

Thorough Action plan must be implemented in order to reach targets in day surgery

TA for Capacity Building for Tertiary Care Services

An EU-funded project managed by the European Agency for Reconstruction

results14
Results

Observation by hospital staff for improvements needed in development of day surgery

  • Space
  • Equipment
  • Change of financing pattern
  • Training and education of manpower
  • Improvement of recording/measurement procedures

TA for Capacity Building for Tertiary Care Services

An EU-funded project managed by the European Agency for Reconstruction

results15
Results
  • Given their magnitude and high case-load, four largest university hospitals in Serbia offer a large area for improvement
    • in quality of care
    • decreasing hospitalization rates and ALOS
    • increasing patient satisfaction
    • decreasing cost per patient.

TA for Capacity Building for Tertiary Care Services

An EU-funded project managed by the European Agency for Reconstruction

results16
Results
  • In each Clinical Centre Work Groups for Day Surgery / Day Hospital were formed to
    • analyze their existing service delivery model and patient flows to be able
    • to meet the MoH target of average 3-5% annual increase in ambulatory care.
  • Some preliminary models of activity-based financing of day procedures such as
    • chemotherapy
    • cataract procedures
    • pace-makers
    • cardiac catheterizations

are already in place.

TA for Capacity Building for Tertiary Care Services

An EU-funded project managed by the European Agency for Reconstruction

conclusions
Conclusions
  • Defining procedure-specific annual percentage rates on the five year period (2008-2012) basis
  • Developing an implementation plan with different targets for each of the 25 potential day cases have been done (eg. 30% of cataract extractions and 20-30% of hernia repairs as day cases in the first year),
  • Mentioned should secure sustainable shift towards ambulatory care model.

TA for Capacity Building for Tertiary Care Services

An EU-funded project managed by the European Agency for Reconstruction