1. The Culture of Healthcare
Welcome to The Culture of Health Care, Health Care Settings—The Places Where Care is Delivered. This is lecture (b).
The component, The Culture of Healthcare, addresses job expectations in healthcare settings. It discusses how care is organized within a practice setting, privacy laws, and professional and ethical issues encountered in the workplace.
Healthcare Settings–The Places Where Care is Delivered
Lecture b
This material (Comp2_unit3b) was developed by Oregon Health and Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC

2. Unit Title Learning Objectives
Differentiate the range of care delivery organizations, including primary care, specialty care, tertiary care, inpatient and outpatient facilities, long-term care hospitals, and long-term care facilities (Lecture a)
Analyze the organization of healthcare delivery from the perspective of a “continuum of care”, such as ambulatory services, in-patient care, long-term care, and end-of-life care (Lecture a)
Evaluate the similarities and differences of community hospitals, teaching hospitals, and community health clinics (Lecture a)
The objectives for this unit, Health Care Settings—The Places Where Care is Delivered, are to:
Differentiate the range of care delivery organizations, including primary care, specialty care, tertiary care, inpatient and outpatient facilities, long-term care hospitals, and long-term care facilities
Analyze the organization of healthcare delivery from the perspective of a “continuum of care” such as ambulatory services, inpatient care, long-term care, and end-of-life care
Evaluate the similarities and differences of community hospitals, teaching hospitals, and community health clinics
Health IT Workforce Curriculum Version 3.0/Spring 2012
The Culture of Healthcare Healthcare Settings—The Places Where Care is Delivered Lecture b

3. Unit Title Learning Objectives (continued)
Describe the various departments and services offered by an outpatient clinic, community hospital, academic medical center, and long-term care facility (Lecture b)
Explain the ways in which these departments interact and the services relate (Lecture b)
Speculate on the data and information that are created and used by people in these departments (Lecture b)
Describe ways in which medical and/or information technology has improved interdepartmental communication and how that has improved the patient experience (Lecture b)
Additional objectives for this unit are to:
Describe the various departments and services offered by an outpatient clinic, community hospital, academic medical center, and long-term care facility
Explain the ways in which these departments interact and the services relate
Speculate on the data and information that are created and used by people in these departments
Describe ways in which medical and/or information technology has improved interdepartmental communication and how that has improved the patient experience
Health IT Workforce Curriculum Version 3.0/Spring 2012
The Culture of Healthcare Healthcare Settings—The Places Where Care is Delivered Lecture b

4. The Structure and Function of Health Care Organizations
Departments and functions of health care organizations
How these organizations interact
Types and use of data by the departments
Technology’s impact on interdepartmental communication and patient experiences
This lecture will provide an overview of departments and services offered by healthcare organizations. It will take a generic approach by describing typical organizational structure and functions of departments and point out specific differences between types of organizations. It will give examples of units within each of the broader departments. It will describe how departments interact; types of data used by the departments; and how Health Information Technology has improved interdepartmental communication and the patient experience.
Health IT Workforce Curriculum Version 3.0/Spring 2012
The Culture of Healthcare Healthcare Settings—The Places Where Care is Delivered Lecture b

5. Healthcare Organization: Organization Chart
This organizational chart displays an overview of what a healthcare organizational structure might look like. It is not intended to be exhaustive but to represent usual divisions and some departments under those divisions. The first box is for management with a link down to each of the displayed divisions. Before it reaches the divisions, there is a dotted line off to the right to medical staff, a quasi-autonomous division that usually reports to the chief medical office or the Chief Executive Officer. The five divisions indicated by boxes linked to management are nursing (with nursing units and nursing education as examples); Clinical Support Services (with physical therapy; radiology and social services as examples); ancillary (with laboratory, transportation, and food services as examples); information (with admitting, medical records, and information technology as examples); and facilities management (with housekeeping, maintenance, and security as examples). The examples are shown in smaller text boxes directly below the division name. Please note that a laboratory could also be listed under clinical support services, since a large part of the department’s function is to run laboratory tests. Many units have functions that cross divisions.
3.2 Chart: Example of a healthcare organizational structure (Hickman 2012, CC BY-NC-SA 3.0).
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The Culture of Healthcare Healthcare Settings—The Places Where Care is Delivered Lecture b

6. Management (Longecker et, 2007)
Chief Executive Officer
Chief Operating Officer
Chief Financial Officer
Chief Medical Officer
Chief Information Officer
Chief Medical Information Officer
The Chief Executive Officer leads the organization and may report to a board of directors or to a system-level President or Chief Operating Officer. The Chief Operating Officer is responsible for the day-to-operations of the healthcare organization. The Chief Financial Officer manages the fiscal aspects of the organization including the operating budget, contracts, income and expenditures, billing, and compensation. The Chief Medical Officer is usually a physician and is the liaison to the medical staff. He/she also has responsibility for clinical care, quality improvement, and sometimes, graduate medical education. The Chief Information Officer is a relatively new role and has gained prominence with the evolution of technology in medical instrumentation and the increased implementation of Electronic Health Records (EHRs). The Chief Medical Information Officer provides a liaison between clinicians and information technology; this has become a critical role with the implementation of EHRs. The Chief Medical Information Officer often reports to the Chief Information Officer, the Chief Medical Officer, or both.
Health IT Workforce Curriculum Version 3.0/Spring 2012
The Culture of Healthcare Healthcare Settings—The Places Where Care is Delivered Lecture b

7. Medical Staff Usually has an elected Chief of Staff Manages
Physician privileges
Medical polices
Governance of medical staff
Continuing medical education
The medical staff is the governing body of the physicians and sometimes other clinicians. It usually has an elected Chief of Staff. Reporting varies, since the medical staff and hospital administration used to be parallel management structures. The Chief of Staff and the Medical Staff Office manages physician privileges and accreditation issues (sometimes including physician extenders), medical policies, governance of the medical staff, and sometimes continuing medical education including at the department level.
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The Culture of Healthcare Healthcare Settings—The Places Where Care is Delivered Lecture b

8. Nursing (University of Rochester Medical Center, 2011)
Chief Nursing Officer
Nursing Units
Ambulatory
Inpatient
Critical Care
Other
Education and Professional Development
Research
The Nursing Division is typically headed by the Chief Nursing Officer who reports to the Chief Executive Officer. Nursing is responsible for managing and staffing all the nursing units. This includes ambulatory units that may comprise primary care or specialty clinics. There also a growing number of ambulatory surgery or procedure nursing units. Inpatient nursing units are where patients admitted to a hospital are managed and given care. This would usually include Pediatrics [pēd-ē-a-triks]; Medicine; Surgery and Obstetrics [əb-ste-triks]-Gynecology [gīn-ə-käl-ə-jē], but may also include subspecialty units like orthopedics [ȯr-(ˌ)thō-pēd-iks]; oncology [än-käl-ə-jē]; or rehabilitation. Critical care units typically include Cardiac Intensive Care; Surgical Intensive Care; Medical Intensive Care; Pediatric Intensive Care; and Neonatal [nē-ō-nāt-əl] Intensive Care but may include more specialized units in academic or specialized hospitals. Other types of units include the Emergency Department, Labor and Delivery, and Surgery (Operating Rooms and the Post Anesthesia [an-əs-thē-zhə] Care Unit). The Nursing Division is also usually responsible for nursing education and professional development training. This sometimes includes training all hospital personnel in areas like Cardio [kärd-ē-(ˌ)ō] -Pulmonary [pu̇l-mə-ner-ē] Resuscitation [ri-ˌsəs-ə-tā-shən]. In academic hospitals, there may be specific ambulatory or inpatient units that function as research units.
Health IT Workforce Curriculum Version 3.0/Spring 2012
The Culture of Healthcare Healthcare Settings—The Places Where Care is Delivered Lecture b

9. Clinical Support Services
Management Varies
Diagnostic
Radiology
Cardiology
Therapeutic
Physical Therapy
Pharmacy
Social Service
The management structure of Clinical Support Services (also called Allied Health) varies depending on the healthcare organization. Some have a management-level officer who reports directly to the Chief Executive Office; some combine Clinical Support Services and Ancillary Services and divide it into Diagnostic and Therapeutic divisions; and in others, the managers of individual Allied Health departments report directly to the Chief Operating Officer or designate. Clinical Support Service departments support the diagnosis and treatment of patients in specialized areas. Examples of diagnostic Allied Health include Radiology [rād-ē-äl-ə-jē], which is responsible for X-rays, other imaging like Magnetic Resonance [rez-ən-ən(t)s] Imaging, and Computerized Tomography [tō-mäg-rə-fē]. Radiology departments also support therapeutic procedures often termed Interventional Radiology. Another would be Cardiology [kärd-ē-äl-ə-jē], responsible for diagnostic studies like electrocardiograms [ĭ-lĕk'trō-kär-dē-ə-grăm], stress tests, and echocardiograms [ek-ō-kärd-ē-ə-ˌgram]. Cardiology also support more invasive diagnostic and interventional studies like cardiac catheterization [kath-ət-ə-rə-zā-shən]. Allied Health Departments that are considered more therapeutic would include physical therapy, which provides care for patients with physical limitations from injuries or disease. Pharmacy is responsible for the acquisition, storage, and dispensing of medication. Social Services is an example of a department that provides patient and family support and counseling, assessment of financial assistance, and discharge planning.
Health IT Workforce Curriculum Version 3.0/Spring 2012
The Culture of Healthcare Healthcare Settings—The Places Where Care is Delivered Lecture b

10. Ancillary Services Management varies Examples Laboratory
Transportation
Food Services
The management structure of Ancillary Services varies depending on the healthcare organization. Some have a management-level officer who reports directly to the Chief Executive Office; some combine Clinical Support Services and Ancillary Services and divide it into Diagnostic and Therapeutic divisions; in others the managers of individual ancillary departments report directly to the Chief Operating Officer or designate. Examples include the laboratory responsible for the collection, analysis, and reporting of laboratory tests. As noted previously, laboratory crosses functions with Clinical Support Services due to the training required to run the analysis of many types of laboratory tests. Another example is transportation, which is responsible for transporting patients within the hospital. This may include transporting patients from admitting to an inpatient unit or from the inpatient unit to a diagnostic service or surgery. Food services is the department charge with preparing and delivering food to patients. They also provide cafeteria services to staff, family members, or visitors. In some hospitals, the food services department reports to the dietetic department.
Health IT Workforce Curriculum Version 3.0/Spring 2012
The Culture of Healthcare Healthcare Settings—The Places Where Care is Delivered Lecture b

11. Information (United Hospital Fund, 2008; Medicare Payment Advisory Committee, 2004)
Management varies
Examples
Admitting
Medical records
Information technology
The management structure of Information Departments varies depending on the healthcare organization. Some have a management level officer who reports directly to the Chief Executive Officer; in others, the managers of individual ancillary departments have a department director who report to the Chief Operating Officer or designate. Admitting is responsible for obtaining initial information from the patient including demographic data, payer information, and reason for admission. They will obtain general consent for admission to the hospital and agreement to pay services not covered by the payer and will acknowledge receiving information about the Health Insurance and Portability and Accountability Act (HIPAA) [hip-pa]. Admitting may also ask patients if they have or would like to complete an advanced directive for care. Medical records traditionally were kept on paper; with the growing shift to electronic records, many medical record departments are transitioning their responsibilities to include some aspects of EHRs. The primary responsibility is to ensure that the medical records meet legal and regulatory requirements.
Information technology departments have always had the responsibility to maintain infrastructure including hardware and software and the security of the data. With implementation of EHRs and greater linkage to data from medical equipment, it has evolved into Health Information Technology. Now, in addition to the use of information technology for administrative and financial functions, it has been expanded to include many clinical functions. This has led to the addition of Chief Information Officers and Chief Medical Information Officers as part of the administrative team.
Health IT Workforce Curriculum Version 3.0/Spring 2012
The Culture of Healthcare Healthcare Settings—The Places Where Care is Delivered Lecture b

12. Facilities Management
Senior Manager
Examples
Housekeeping
Maintenance
Security
Facilities is often led by a senior manager who reports to the Chief Operation Officer. The departments are largely involved in managing the facility as a whole; this can include structures and grounds. The Housekeeping department is responsible for cleaning and may include the laundry. Maintenance involves day-to-day repairs and replacement but also includes complex maintenance like electrical, backup generators, and heating and cooling. Security is often included in facilities management and is responsible for security issues such as parking control, identification badges, and securing patient belongings when they are admitted.
Health IT Workforce Curriculum Version 3.0/Spring 2012
The Culture of Healthcare Healthcare Settings—The Places Where Care is Delivered Lecture b

13. Organizational Structure by Institution
Core functions
Size
Type
All healthcare organizations have certain core functions required to deliver healthcare—management, medical staff, nursing, clinical support, ancillary support, information, and facilities management. How these functions are manifested have to do with the size and type of the organization. A small community health clinic may be administered by the senior physician and an office manager. The medical staff may consist of only a few providers. Nursing staff may include a single nurse and several medical assistants. The medical assistants also provide limited clinical support and Ancillary Services (office laboratory tests or simple diagnostic procedures). The office manager and receptionist may provide much of the registration, billing, referral, and medical records. Facilities management may be a combination of the office staff and contracted cleaning and maintenance. As facilities grow, these functions tend to require more personnel and personnel with additional training and eventually require whole divisions with multiple departments. Community health clinics do not perform complex diagnostic or treatment procedures. Community hospitals and academic hospitals may have similar organizational structure for clinical care. Academic hospitals add the need for two new functions—teaching and research. These can be substantial undertakings that require divisions and personnel to accomplish these tasks.
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The Culture of Healthcare Healthcare Settings—The Places Where Care is Delivered Lecture b

14. Data Types (Shortliffe EH, Barnett GO, 2006)
Narrative, textual
Numerical measurements
• Recorded signals
• Drawings
• Photographs and images
Several types of data are used to gather and record information. Much of the observational data such as the history, results of the physical examination, procedure, and surgery reports are recorded as narrative data. Numerical measures include weight, vital signs, and volumes. Recorded signals are increasingly digital and can be transferred directly to EHRs. This includes electrical activity (electrocardiograms [ĭ-lĕktrō-kär-dē-ə-grăm']) and pressures generated from a variety of monitoring devices like blood pressure and other measures of cardiac pressures. Many devices like intravenous fluid administration devices or ventilators now have the ability to directly input data into EHRs. Drawings, either produced by hand or with software, provide a record of an observation made to aid in documenting or following the progress of a wound, surgery, injury, etc. Photographs and images are becoming more common in digital format and allow one to record an abnormal finding or wound at admission to better follow the progress. Many healthcare organizations now record all X-rays and imaging in digital format.
Health IT Workforce Curriculum Version 3.0/Spring 2012
The Culture of Healthcare Healthcare Settings—The Places Where Care is Delivered Lecture b

15. Communication Verbal Paper Film/Analog Digital
Data can be transmitted verbally face to face or by phone. This has the advantage of direct communication but usually has no permanent record. Even audio recordings may be less satisfactory because they require the user to listen to the entire recording. Paper medical records have been the mainstay of communication. There are problems with legibility and organization, and the record can usually only be one place at one time. Frequently, this means that many units keep their own version of the medical record and only inpatient records are uniform. In the past, many results of tests or images were recorded on film or in an analog format. While these could be added to the chart (electrocardiograms or laboratory results) or stored in a central location (X-rays), this method has the same availability problems as paper records. Digital records have the potential to replace permanent records across the institution, avoid duplicate entry of information like demographics, and allow access to view and enter data at multiple locations. Increasing use of digital imaging also allows any user with authorization to view images including real-time images like ultrasounds.
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The Culture of Healthcare Healthcare Settings—The Places Where Care is Delivered Lecture b

16. Patient Experience History Testing Information access
Patients seem to be responding positively to the enhanced communication among health organizations as a result of the implementation of Electronic Health Records, especially the elimination of having to provide duplicate information for every visit to a new department or when receiving a new service. The amount of data is difficult for patients to keep track of and understand as it may include demographic information, health insurance, current medications, allergies, and details of the current and past illnesses. Patients were also confused, for example, when a test or x-ray was repeated when they visited a new department or received a new service, despite the fact that the same test or x-ray was performed just weeks earlier. Electronic Health Records have enabled all departments within a healthcare institution or system access to the results of every test or visit that has occurred with each patient, significantly decreasing the need for patients to attempt to repeatedly explain their interpretation of previous visits or services as well as eliminating the process of requesting records from other departments to assess the patient’s status.
Health IT Workforce Curriculum Version 3.0/Spring 2012
The Culture of Healthcare Healthcare Settings—The Places Where Care is Delivered Lecture b

17. Healthcare Settings—The Places Where Care is Delivered Summary – Lecture b
Range and “Continuum of Care”
Unique types of health care organizations and relationships between organization
Organizational structure and function
Relationship and communication between departments
Effect of technology on the patient experience
This concludes Lecture (b) of Health Care Settings–The Places Where Care is Delivered. The lecture described departments and services offered by outpatient clinics, community hospitals, academic medical centers, and long-term care facilities, including interactions between departments and the services they deliver. The lecture discussed data and information concerns and described how information technical has affected interdepartmental communication and improved the patient experience.
Health IT Workforce Curriculum Version 3.0/Spring 2012
The Culture of Healthcare Healthcare Settings—The Places Where Care is Delivered Lecture b

18. Healthcare Settings—The Places Where Care is Delivered―Summary
Differentiate range of care delivery organizations
Analyze the organization of healthcare delivery from the perspective of a “continuum of care”
Evaluate similarities and differences of community hospitals, teaching hospitals, community health clinics
Describe departments and services offered
Explain how departments and services interact
Discuss data and information
Describe impact of medical and/or information technology
This also concludes Healthcare Settings—The Places Where Care is Delivered. The unit provided a summary of the range of healthcare organizations including those that provide primary care, secondary care, and tertiary care. It presented a description of some the unique healthcare organizations and relationships between them as well as a description of the general organizational structure of healthcare organizations. Each division and examples of departments that might be in those divisions was discussed, including communication of medical data. Finally, the unit described the effect of technology, both on interdepartmental communication and the patients’ experience.
Health IT Workforce Curriculum Version 3.0/Spring 2012
The Culture of Healthcare Healthcare Settings—The Places Where Care is Delivered Lecture b

19. Healthcare Settings—The Places Where Healthcare is Delivered References – Lecture b
Longnecker DE, Patton M, Dickler RM. (2007). Roles and responsibilities of Chief Medical Officers in member organizations of the Association of the American Medical Colleges. Academic Medicine, 82(3), Retrieved Jan 2012 from
Medicare Payment Advisory Committee. (2004). Chapter 7: Information technology in health care. In Report to the Congress: new approaches in Medicare. Retrieved Jan 2012 from:
Scribd. (2011). Organizational structure of a hospital. Retrieved Jan 2012 from
Shortliffe EH, Barnett GO. (2006) Biomedical data: their acquisition and use In: Shortliffe EH, Cimino JJ, eds. Biomedical Computer Applications in Health Care and Biomedicine. 3rd ed. New York, NY: Springer; 2006: p
United Hospital Fund. (2008). Family care giver guide. Hospital admission: how to plan and what to expect during the stay. Retrieved Jan 2012 from
University of Rochester Medical Center. (2011). Strong Memorial Hospital organizational chart. Retrieved Jan 2012 from
Images
3.2 Chart: Example of a healthcare organizational structure (Hickman 2012, CC BY-NC-SA 3.0).
References slide. No audio.
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The Culture of Healthcare Healthcare Settings—The Places Where Care is Delivered Lecture b