1. Delmar Learning Copyright © 2003 Delmar Learning, a Thomson Learning company Nursing Leadership & Management Patricia Kelly-Heidenthal 0-7668-2508-6

2. Delmar Learning Copyright © 2003 Delmar Learning, a Thomson Learning company Chapter 1 America’s Health Care Environment

3. Chapter 1Copyright © 2003 Delmar Learning, a Thomson Learning company3 Objectives  Upon completion of this chapter, the reader should be able to: Identify how health care is organized and funded in America. Discuss the movement toward population-based health care and disease management. Discuss health care variation, evidence-based practice, and malpractice. (continues)

4. Chapter 1Copyright © 2003 Delmar Learning, a Thomson Learning company4 Objectives Review the Institute of Medicine’s Committee on Health Care reports. Identify recent changes and current forces and trends influencing the development of caring, transdisciplinary nursing, and health care delivery in America.

5. Chapter 1Copyright © 2003 Delmar Learning, a Thomson Learning company5 Organization of Health Care  The unique American political and social outlook has influenced the development of American health care.  Americans have resisted the development of a coordinated, centralized, national health care system.  Health care in America uses a variety of different resources.

6. Chapter 1Copyright © 2003 Delmar Learning, a Thomson Learning company6 Types of Health Care Services  Primary – Emphasize promotion of health and prevention of illness or disability.  Secondary – Emphasize detection and early intervention in illness to prevent further illness and disability.  Tertiary – Provide restorative or rehabilitation services for patients with chronic or irreversible conditions.

7. Chapter 1Copyright © 2003 Delmar Learning, a Thomson Learning company7 Public and Private Stakeholders and Settings  Public stakeholders include tax-supported agencies at the national, state, and local levels.  Private stakeholders include health care deliverers and other organizations that operate in the health care field.  Voluntary groups also operate in the health care arena. Examples of such groups are the American Nurses Association, American Red Cross, and American Heart Association.

8. Chapter 1Copyright © 2003 Delmar Learning, a Thomson Learning company8 Health Care Spending  The United States ranks 18th in the world in overall health.  A large number of Americans do not have health insurance.  A large portion of health care dollars is spent on illness care rather than on preventative care.

9. Chapter 1Copyright © 2003 Delmar Learning, a Thomson Learning company9 Health Care Funding  The U.S. government provides health care funding for military personnel, veterans, and Native Americans.  Through Medicare, the U.S government provides health care funding for citizens who are over the age of 65 or disabled.  Through Medicaid, the U.S government provides health care funding for the medically indigent. (continues)

10. Chapter 1Copyright © 2003 Delmar Learning, a Thomson Learning company10 Health Care Funding  Medicare and Medicaid use a fee-for-service system that increases the total number of fees when the number of patient services increases.  This system has led to escalating medical costs.

11. Chapter 1Copyright © 2003 Delmar Learning, a Thomson Learning company11 Health Maintenance Organization Act Health Maintenance Organization Act  The U.S. Congress passed this act in 1973. It encouraged the formation and proliferation of health maintenance organizations (HMOs).  In the 1990s large numbers of Americans began enrolling in HMOs.  HMOs use a payment method called capitation, which is the payment of a fixed dollar amount, per person, for the provision of health services to a patient population for a specified period of time.

12. Chapter 1Copyright © 2003 Delmar Learning, a Thomson Learning company12 Managed Care  Managed care manages quality and cost of health care.  It uses a variety of methodologies.  It also uses various care models, such as preferred provider organizations (PPOs), point of service plans (POSs), and traditional HMOs.  Many are concerned that managed care has adopted cost-cutting strategies that are compromising effective health care.

13. Chapter 1Copyright © 2003 Delmar Learning, a Thomson Learning company13 Tax Equity and Fiscal Responsibility Act  This act put a ceiling on Medicare reimbursement for hospital services.  It set the stage for the 1983 Social Security amendments, which mandated a prospective payment system (PPS).  PPS resulted in the establishment of diagnosis-related groups (DRGs) to permit comparison of similar admissions and regulation of their cost.

14. Chapter 1Copyright © 2003 Delmar Learning, a Thomson Learning company14 Movement Toward Population-based Health Care and Disease Management  Population-based health care  Addresses the needs of a population of patients rather than focusing on care delivery to meet the needs of individual patients.  Multiple determinants of health  Interest has grown in the role of social, environmental, economic, and genetic factors in individual and group health.  Increased emphasis is on spending on health prevention and education.

15. Chapter 1Copyright © 2003 Delmar Learning, a Thomson Learning company15 Integrated Health Care Delivery Systems  A network of health care organizations that provides or arranges to provide a coordinated continuum of services to a defined population and is willing to be held clinically and fiscally accountable for the outcomes and the health status of the population served. (continues)

16. Chapter 1Copyright © 2003 Delmar Learning, a Thomson Learning company16 Integrated Health Care Delivery Systems  Networks can be horizontally integrated when a system contains several organizations of one type.  Networks can be vertically integrated when different stages of health care are linked and delivered by one agency.

17. Chapter 1Copyright © 2003 Delmar Learning, a Thomson Learning company17 Disease Management  A systematic approach to identifying at-risk persons and intervening with care and prevention programs.  Provides cost containment by attempting to prevent development of more serious health care conditions.  Rationing care  Process of using outcomes data to rank different types of care, either for selection of patients or reimbursement by agencies.

18. Chapter 1Copyright © 2003 Delmar Learning, a Thomson Learning company18 Accreditation  The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is the national organization that develops standards and accredits health care organizations.  Accreditation is one of the ways hospitals can be certified to receive Medicare and Medicaid payments (continues)

19. Chapter 1Copyright © 2003 Delmar Learning, a Thomson Learning company19 Accreditation  JCAHO initially emphasized standards for how hospitals should be structured and set up for accreditation. It has broadened its approach and identified patient and organization outcomes to be reviewed for quality.

20. Chapter 1Copyright © 2003 Delmar Learning, a Thomson Learning company20 Health Care Variation, Clinical Practice Guidelines, and Malpractice  Research in the 1970s indicated that patient outcomes and costs varied significantly in different parts of America.  In 1989 the Agency for Healthcare Research and Quality (AHRQ) was formed to develop clinical practice guidelines for uniformly measuring quality of outcomes.  Concerns over malpractice have also led to an emphasis on measuring and documenting outcomes.

21. Chapter 1Copyright © 2003 Delmar Learning, a Thomson Learning company21 Institute of Medicine Committee on Health Care Quality Reports  An Institute of Medicine (IOM) committee report released in 2001 identified six major areas to be pursued in health care. Health care should be: Effective Patient-centered Timely Efficient Safe Equitable (continues)

22. Chapter 1Copyright © 2003 Delmar Learning, a Thomson Learning company22 Institute of Medicine Committee on Health Care Quality Reports  It also identified four major areas to target for change: Information technology Payment Clinical knowledge Professional workforce

23. Chapter 1Copyright © 2003 Delmar Learning, a Thomson Learning company23 Quality Health Care  Donabedian conceptualized a useful framework for quality health care. It uses the elements structure, process, and outcome.  Structure elements, such as quality patient care standards, environmental standards, and so on, identify what structures must be in place to deliver quality health care. (continues)

24. Chapter 1Copyright © 2003 Delmar Learning, a Thomson Learning company24 Quality Health Care  Process elements, such as managing the health care process and using clinical practice guidelines, identify what nursing and health care interventions must be in place to deliver quality.  Outcome elements are the end products of quality care and indicate the patient status that results from health care. They reflect the effectiveness of structure and process elements.

25. Chapter 1Copyright © 2003 Delmar Learning, a Thomson Learning company25 Balanced Scorecard  The balanced scorecard is a means of monitoring outcomes and reviewing quality and cost.  It uses four key perspectives as a framework for identifying measures to be reviewed in an organization: Financial strength Customer satisfaction and service Internal operating efficiency Learning and growth  Each perspective has five or six vital measures.

26. Chapter 1Copyright © 2003 Delmar Learning, a Thomson Learning company26 Malcolm Baldridge National Quality Award  This national award annually recognizes quality achievement in various industries.  A pilot program for the health care industry was conducted in 1995, and health care organizations were eligible to apply for the award in 1999.

27. Chapter 1Copyright © 2003 Delmar Learning, a Thomson Learning company27 Recent Changes in Health Care  Health Insurance Portability and Accountability Act (HIPAA) of 1996  Includes measures to standardize and computerize health care billing, claims, and reimbursement. Also dictates that patient data be transmitted securely.  Public information about the quality of health plans (continues)

28. Chapter 1Copyright © 2003 Delmar Learning, a Thomson Learning company28 Recent Changes in Health Care  Several public and private agencies are making public information on the quality of patient care. This information is being used for comparison purposes.  Other organizations compile ratings and rankings of health care organizations across the country.

29. Chapter 1Copyright © 2003 Delmar Learning, a Thomson Learning company29 The Pew Health Professions Commission’s Report  This report calls for nursing, medical, and other health care curriculums to change and move into the 21st century. It also recommends competencies that will enable health care providers to improve patient care.

30. Chapter 1Copyright © 2003 Delmar Learning, a Thomson Learning company30 Other Forces Currently Influencing Health Care  Capitation  Payment of clinicians based on performance, using clinical guidelines  New technology  Aging population  Genetic engineering (continues)

31. Chapter 1Copyright © 2003 Delmar Learning, a Thomson Learning company31 Other Forces Currently Influencing Health Care  Increasing cultural diversity  New diseases  Information management  Globalization of the world economy

32. Chapter 1Copyright © 2003 Delmar Learning, a Thomson Learning company32 Healthy People 2010  A major public health initiative drafted by the U.S. Department of Health and Human Services.  It contains a set of indicators that provide a snapshot of the nation’s health.

33. Chapter 1Copyright © 2003 Delmar Learning, a Thomson Learning company33 Trends in American Health Care and the Need for Caring, Transdisciplinary Nursing  Nursing role Nursing has increasingly become an integral part of the health care delivery environment. Nurses are assuming more and more responsibility in health care. Transdisciplinary nursing encourages nurses to work together to provide quality patient care.