1. Nurses Registered Nurses - real nurses LPN - licensed practical nurses Nurse Practitioners non-licensed caregivers

2. Nurse-Patient Relationship Nurses are independently licensed Nurses have an independent duty to patients Nurses exercise independent judgment

3. Independent Nurse Practice Nurses may open an office and do wound care and nutrition advise Nurses may not open an office and practice medicine even if they are nurse practitioners Nurses may not be hired by a hospital to set up a medical practice

4. Nurses in Institutions Nurses in hospitals and clinics are generally employees of the institution The institution is generally responsible and liable for what they do. If a physician hires a nurse, the physician takes on these responsibilities

5. Nurse-Physician Relationship In most settings, nurses are absolutely subservient to doctors A nurse may refuse an order but may not change an order Nurses may be protected from bad orders by the practice acts or the rules of the hospital

6. Nurse Extenders lower level care providers medical assistants, surgery technicians, lab technicians on the job training vs certification

7. Nurse Extenders in Institutions need to be carefully screened need to be carefully supervised institution has all the responsibility cannot rely on the license or certification

8. Other Providers Many other health care professionals Doctors –physicians, psychologists, dentists –independent – some with limitations Technicians –x-ray, laboratory, pharmacy –legally and administratively similar to nurses

9. Administrators great responsibility - little authority when it comes to patient care laws forbid corporate practice of medicine need good contracts and institutional rules so they can control what goes on some states license or register administrators

10. STRUCTURE OF HEALTH SYSTEMS 20 February 2009

11. WHAT IS HEALTH ? A STATE OF COMPLETE PHYSICAL, MENTAL AND SOCIAL WELL-BEING, NOT MERELY THE ABSENCE OF DISEASE WORLD HEALTH ORGANIZATION

12. WHAT IS HEALTHCARE ? HEALTH CARE IS THE TOTAL SOCIETAL EFFORT FOCUSED ON PERSUING HEALTH MAY ACT ON INDIVIDUALS OR THE ENVIRONMENT EXPANDED GREATLY OVER THE LAST 40 YEARS

13. PUBLIC HEALTH VS PERSONAL HEALTH PUBLIC HEALTH - TO IMPROVE THE HEALTH OF A POPULATION PERSONAL HEALTH - TO IMPROVE THE HEALTH OF THE INDIVIDUAL

14. US PUBLIC HEALTH SYSTEM Local System – very political Governed by Boards of Health Health Officer/Director

15. HEALTH DEPARTMENTS Environmental Management –Vectors –Water quality –nuisances Disease Control –Clinics –Epidemiology Personal Health Services

16. PREVENTION PRIMARY - PREVENTION OF DISEASE SECONDARY - PREVENTION OF CONSEQUENCES OF DISEASE TERTIARY - PREVENTION OF DEATH OR DISABILITY

17. HEALTHCARE ORGANIZATIONS Hospitals Residential Care Home Services Physicians’ Offices – 37% Dentists’ Offices – 20% Other Practitioners Offices Ambulatory Care Centers Other Outpatient Services Lab, Xray, & Other Diagnostics Day Care

18. INTEGRATED ORGANIZATIONS HOSPITALS, PHYSICIANS, INSURERS, AND PURCHASERS FORM VERTICALLY AND HORIZONTALLY INTEGRATED ORGANIZATIONS IN OTHER CONTEXTS THESE ARE CALLED MONOPOLIES

19. HORIZONTAL INTEGRATION LINKING ORGANIZATIONS OF THE SAME TYPE TO INCREASE MARKET SHARE MEDICAL EXAMPLE –BUYING ALL THE NURSING HOMES MONOPOLY EXAMPLE –AT&T, Cox Cable

20. VERTICAL INTEGRATION LINKING ORGANIZATIONS SO THAT SUCCEDING TRANSACTIONS STAY WITHIN THE SYSTEM MEDICAL EXAMPLE –OCHSNER CLINIC MONOPOLY EXAMPLE –STANDARD OIL

21. HIGHLY INTEGRATED HEALTH SYSTEM VERTICAL INTEGRATION AND AN INSURANCE CONTRACT BIG MOVE TOWARD THIS IN THE 1980s AND 1990s TREND IS NOW AWAY FROM VERTICAL INTEGRATION

22. TRIAD OF GOVERNANCE Governing Body CEO Professional Staff Organization

23. Hospital Medical Staff Bylaws are the structure –Not like corporate bylaws Licensed Independent Practitioners –Their contract with the hospital

24. Practitioner Relationship with the Hospital 1) simple privileges 2) contractor – radiology 3) employee – medical director 4) employee/learner – residents 5) extenders – any of the above

25. Credentialing Prove training and experience National Practitioner Data Bank Major liability for the hospital

26. Impaired Practitioners 8 to 15% of physicians 10% of nurses Required reporting Formal rehabilitation programs Used to be handled by the medical staff Now the hospital’s problem

27. Management Skills There is special training for healthcare administration Getting an MD or a BSN does not make you too stupid to learn this