Management as a function of quality assurance

Health Care Delivery Systems and forms of
Business Organizations
Prof Dr. Reda Eweda
• PhD. In Physical Therapy . Cairo University
• Lecture of orthopedic physical therapy. Cairo
University
• Assistant Professor of orthopedic physical therapy .
Taibah University .KSA

Introduction
• The World Health organization (WHO), which was
established in 1948, has always had as a major
objective the attainment by all people of the highest
possible level of health.
• Health according to the WHO definition is "a state of
complete physical, mental and social well being and not
merely the absence of disease or infirmity".

Primary Health Care (PHC)
• Primary Health Care is defined as essential health Care based
on practical, scientifically sound, and socially acceptable
methods and technology made universally accessible to
individual and families in the community through their full
participation and at a cost that the community and country can
afford to maintain at every stage of their development in the
spirit of self reliance and self determination

• Primary Health Care forms an integral part of both the
country's health system, of which, it is the central function
and main focus and the overall social and economic
development of the community.
• Primary Health Care forms the first level of contact of
individual, the family and the community with the national
health system, brining health care as close as possible to
where people live.

Primary Health Care principles
The following principles underline the concept of PHC
• Intersect oral collaboration
• Community participation
• Appropriate technology
• Equity
• Focus on prevention and health promotion
• Decentralization

1- Intersect oral Collaboration
• Inter-sect oral collaboration is one of the key principles of PHC.
• It means a joint concern and responsibility of sectors responsible for
development in identifying problems, programs and undertaking tasks
that have an important bearing on human well being.
• Health has several dimensions that can be affected by other sectors.
• The cause of ill health are not limited to factors related to the health
sector.

• Education for literacy, income supplementation, clean water, sanitation,
improved housing, ecological sustainability, more effective marketing of
products, construction of roads and water ways, enhanced roles of
women, are changes that may have substantial impact on health.
• The reverse is also true that economic, social and cultural development
cannot proceed smoothly without concomitant and consequent health
development.
• Health therefore is fundamental to socio-economic development and
plays a critical role.

Why is intersect oral collaboration important?
-To save resources (effective use of resources)
-To identify community needs together
Which are the sectors that should collaborate?
-All those sectors involved in the development process such as Health,
Agriculture, Education, Information, transport and communication,
housing and non governmental organization (NGOs).
What hinders inter sectorial collaboration?
-Lack of communication between different sectors
How can we promote intersectional collaboration?
-By forming bodies from relevant agencies and elders at different levels,
starting from the community.

2- Community Involvement
• Community: Is a collection of people living together in some form of social
organization and cohesion.
• Its members share in varying degree of political, economic, social and cultural
characteristics as well as interests and aspirations including health.
• Community involvement Is the process by which individuals and families
assume responsibility for the community and develop the capacity to contribute
to their health and the community's development.
• It is a means by which communities can play a more influential role in health
development, in which the emphasis is on strengthening the capacity of
communities to determine their own needs and take appropriate action.
• Communities should not be passive recipients of services.
• Every body should be involved according to his/her ability.

3- Appropriate Technology
• Take account of both the health care needs and the socioeconomic context of
a country. This must include consideration of:-
A- Costs
Appropriate technology does not necessarily mean low cost.
B- Efficiency and effectiveness in dealing with health problems.
C- Acceptability of the health approach to both target community and health
service providers.
D- Broader social and economic effects.
E- The sustainability including the capacity to maintain equipment of the
approach.
• Based on these points, all levels of health system have to review their
methods, equipment and techniques.

Criteria for Appropriateness
To be appropriate, a technology must be:-
• Effective
- it must work and fulfill its purpose in the circumstances in which it needs to be used.
• Culturally acceptable and valuable.
• Affordable. i.e. cost effective.
• Locally Sustainable.
-We should not be over dependent on imported skills and supplies for its continuing function,
maintenance and repair.
• Possessive of an evolutionary capacity.
-A technology is highly appropriate if its introduction and acceptance can lead to further
benefits.
• Environmentally accountable.
-The technology should be environmentally harmless or at least minimally harmful
• Measurable
- The impact and performance of any technology needs proper and continuing evaluation, if it
is to be widely recommended.
• Politically responsible

4- Equity
• In view of the magnitude of health problems, the inadequate, inequitable
distribution of health resources between and within countries, and believing
that health is a fundamental human right and world-wide social goal, the
conference called for a new approach to health and health care.
Possible definition of equity include:-
• Equal health
• Equal access to health care
• Equal utilization of health care
• Equal access to health care according to need
• Equal utilization of health care according to need
• Planning for equity in PHC requires the identification of groups which are
currently disadvantaged in terms of health status access to or utilization of
services.

5-Focus on Prevention and Promotion of Health Services
• Health promotion relates to the importance of adopting, where
possible a promotive or preventive approach to health problems.
• Such an approach sees health as a positive attribute, rather than
simply" the absence of disease".
• One of the important tasks of the planner is to redress the imbalance in
allocation of resources to preventive and curative care, enhancing the
role of resources available to prevention and promotion.

6- Decentralization
• Decentralization away from the national or central level brings decision making
closer to the communities served and to field level providers of services, making
it more appropriate.
• Decentralization may enhance the ability to tap new sources for financing health
care.
• Finally, by breaking down the large, monolithic decision making structures,
typical of many national ministries, decentralization may lead to greater
efficiency in service provision.

• However decentralization may lead to geographical inequalities in
resource availability and technical quality.
• If handled inappropriately decentralization may actually result in a
shift away from the principles of PHC.
• Planners should, therefore, consider whether specific strategies and
decisions will enhance or hinder the achievement of PHC.

Components/Elements of PHC
Essential Health Care consisting of at list 8 Elements
1- Immunization
• Immunization against six major childhood diseases namely:
Tuberculosis - Poliomyelitis – Diphhtheria - Tetanus -Measles
2- Food Supply and Proper nutrition
• Promotion of food supply and proper nutrition
• Improve food supply at family level
• Correction of faulty feeding practices
• Treatment and rehabilitation of malnourished children
• Treatment and prevention of nutritional diseases
3- Water and Sanitation
• An adequate supply of safe water and basic sanitation.
• To prevent disease and improve quality of life

4- Appropriate Treatment of Common Diseases and Injuries
5- Health Education
• Education for promotion of health
• Education for prevention of disease
• Education for maintenance of health
• Education to deal with disease
6- Maternal and Child Health Care Including Family Planning
• Antenatal care
• Delivery care
• Postnatal care
• Child care
• Family planning
7- Providing of Essential Drugs
• Safe and effective drugs including vaccines
• Promoting the rational use of drugs

8- Additional elements incorporated
A- Oral Health
B- Mental Health
C- The use of traditional Medicine
Advantages of traditional healers
• Some treatments are effective
• They are accepted and people trust them
• They are easily accessible
Disadvantages of traditional healers
• Some traditional practices are harmful
• Traditional healers are sometimes expensive
• Lack of knowledge of distinction between diseases
D- Occupational Health, control of HIV/AIDS

Health Care Delivery Systems
Definition of health care
- It is the total societal effort, organized or not, whether private
or public, that attempts to guarantee, provide, finance, and
promote health - changed markedly during the 20th century
toward more prevention's.
Definition of health services
- They are the delivery component of health care. They are
provided by practitioners and organizations and have gone
through significant changes.

Definition of system
- A set of inter-connected parts that have to function together to be
effective
Definition of health system
- It consists of all organizations, people and actions whose primary intent is
to promote, restore or maintain health(WHO2007)
Medical Care
• Medical care is a process or activity in which certain inputs or factors of
production (such as doctors’ and nurses’ services, services of medical
instruments and equipment, and pharmaceuticals) are combined in varying
quantities to yield an output. Thus HSOs are settings in which inputs
(resources) are converted to output (work results and objective
accomplishment). Management is the catalyst

Medical Care
1/1/2024 Dr. Mohammed Alnaif 21
Input
Resources
Conversion
Process
Output
work results
& objective

Function of Health care delivery system
• The main function of health care delivery and quality of care is to increase the
coverage and quality of promoting, preventive and curative activities.
• If a better performing health system is to be attained, adequate and motivated
personnel, availability of medical supplied and sustainable financial resources
are conditions to achieve such as objective.
• The main purpose of the health service is to give a comprehensive and
integrated primary health care at the community level.
• The approach will be to emphasize on the preventive and promotive aspect of
health care without neglecting essential curative services.

Delivery System Design
The delivery system presents at multiple levels
– Regional/National: macrosystem
– Integrated Medical Care Organization: mesosystem
– Practice level: microsystem
Benefits of Delivery System Design
• Define population of patients
• Define roles and distribute tasks amongst team members.
• Use planned interactions to support evidence-based care.
• Provide clinical care management services.
• Ensure regular follow-up.
• Give care that patients understand and that fits their culture

Health Services Organizations (HSOs)
• Delivery of health services involves the organized public or private efforts that
assist individuals primarily in regaining health, but also in preventing disease and
disability.
• Delivery of services to patients occurs in a variety of settings.
• All HSOs can be classified by structure, functions, ownership, and profit motives.
• Historically, hospitals and nursing facilities have been the most common and
dominant HSOs engaged in delivery of health services.
• They remain prominent in the contemporary health services system, but other
HSOs have achieved stature.

Benefits of health care organization
• Quality as core strategy
• Visibly support improvement at all levels, starting with senior and leaders.
• Promote effective improvement strategies aimed at comprehensive
system change.
• Encourage open and systematic handling of problems.
• Provide incentives based on quality of care.
• Develop agreements for care coordination.

Managed Care (Business and Clinical Issues)
• The managed care industry and managed care organizations (MCOs)
represent a radical change in the practice of medicine and the delivery of
health care
• Historically, the practice of medicine and the delivery of clinical care were
managed separately from the operations of the physician's office,
hospital, or other healthcare facility.
• As a result, two clear layers of operations and administration grew up in
American health care, with corresponding organizational structures.

1- The clinical layer
• It encompassed operations directed specifically at medicine and care delivery.
These include (patient diagnosis and treatment, as well as patient care in the
hospital (e.g., administering drugs and other therapies, feeding and bathing the
patient, and so on).
2- The business or administrative layer
• It consisted of procedures that supported, housed, or paid for the clinical
operations: (patient registration, insurance, billing, claims submission, and
reimbursement management).
• This new environment is much more complex, especially in its clinical and business
integration aspects.

• Today's typical MCO must manage thousands of physicians, in addition to
hospitals and other healthcare providers as part of one or more provider
networks.
• These networks also force the MCO to cope with various benefit plans associated
with multiple employers, hundreds of provider contracts (all with different
effective dates, payment rates, and varying degrees of risk), and the tens of
thousands of members accessing the network(s) .
• The MCO also must administer unique medical management and reporting
requirements and deal with complex coordination of benefits issues associated
with secondary insurers.

• The objective of MCO operations is to ensure that the care delivered
under managed care contracts is appropriate to the patient's medical
condition, provided in the proper setting, and delivered in the most cost-
effective manner.
• For example, a hospital stay is not authorized for a clinical procedure that
can be done safely in the physician's office. To do this, the MCO applies
operational controls at various checkpoints in the care delivery process
and collects a considerable amount of detailed information to refine its
operations and products.

Managed Care Operational Categories
An integrated and comprehensive managed care operational environment
requires the following four categories of managed care operational support:
(1) member point-of-care
(2) daily operational processes
(3) administrative
(4) information administration.

(1) Member point-of-care
• Member point-of-care, involves processes that support members at the
point-of-care delivery.
• These are "medical management“ activities like demand management,
referral management, disease management, and the more traditional
utilization management (including case or care management).
• The objective of these interventions is to provide members with the
most appropriate type, level, and quantity of care for a particular
episode.

• By managing the conditions under which members access and receive
care, these operational processes have a major impact on both
member satisfaction and health plan financial performance.
• For example, in a demand management program, an ill member may
telephone his or her problem to a 24-hour "advice" nurse and receive
assistance over the phone that can prevent a costly and unnecessary
emergency room visit.

(2) Daily operational processes
• Daily operational processes support the day-to-day workings of the MCO through
"back office" operations.
• These day-to-day transaction processing activities required for MCOs include
paying claims, handling member and provider inquiries, and marketing to
different types of consumers, and they are often neglected in discussions of
managed care
(3) Administrative
• The administrative category encompasses operations that provide the
retrospective financial and quality analysis of operations. These are typically
month-end or period-end activities like capitation management and financial
statement production

(4) information administration.
• The final category, information administration, provides the
necessary data and information support to ongoing
operations for an MCO.
• This would include activities like the Health Plan Employer
Data and Information Set (HEDIS) reporting, provider
profiling, and report cards

Roles of managed care organizations
• There are several ways in which managed care organizations play important roles
in ensuring a full continuum of high-quality patient care services.
• These approaches set managed care apart from the traditional fee-for-service
system and include:
1. Services system planning.
2. Case management.
3. Benefit redesign.
4. Quality management.

1- Services system planning
• The organizational and financial mechanisms developed by managed care
organizations were designed to reduce the fragmentation of services common
in mental health systems and to allow "the dollars to follow the patient."
• Managed care organizations, unlike fee-for-service plans, take a systems view of
the patient and of services required to provide a full continuum of care.
• The patient is seen as potentially moving among various levels of care, from
acute to partial hospitalization, day treatment, intensive outpatient, and
routine outpatient appointments with a clinician.

2- case management
• Elements of case management include case identification, coordination and
referral, treatment and discharge planning, and follow-up. In contrast to fee-
for-service payment, case managers in managed care organizations authorize
services based on the individual patient's specific, current needs.
• Case management may begin on entry to the managed behavioral care
system, when an intake coordinator briefly assesses the patient's presenting
problems, identifies whether the situation requires emergency intervention,
verifies the benefit coverage, and authorizes a limited number of initial
therapy sessions.

3- Benefit redesign
• One unfortunate characteristic of traditional fee-for-service payment is that it
does not subject the provider to review for clinical necessity or clinical
quality.
• As a result, many payers now attempt to reduce unnecessary costs of care by
limiting coverage of outpatient care or alternatives to hospitalization such as
day treatment programs.
• On a case by- case basis, case managers in a managed care organization must
advocate for benefit extensions or substitutions when overly restrictive plans
interfere with optimal service delivery.

4- Quality management
• Managing quality within managed care service delivery systems is a
complex and ongoing task of increasing interest and importance to
many players, including payers, accreditors, providers, consumers,
and the managed care organization itself.
• Elements of quality management include credentialing, utilization
review, case audits, quality improvement, and mechanisms to ensure
accountability

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