N. NANTE In collab con G.MESSINA e G.SPATARO. Programmazione ed organizzazione delle Aziende Sanitarie (MED/42)

Transcript

1 Università di Siena CORSO DI LAUREA IN INGEGNERIA GESTIONALE C.I. Programmazione, Organizzazione e Gestione delle Aziende Sanitarie a.a. 2014/2015 DISCIPLINE Programmazione ed organizzazione delle Aziende Sanitarie (MED/42) Basi di Epidemiologia e di Economia Sanitaria (MED/42) DOCENTI N. NANTE In collab con G.MESSINA e G.SPATARO C. QUERCIOLI

2 Università degli Studi di Siena CORSO DI LAUREA INGEGNERIA GESTIONALE C. I. Programmazione, Organizzazione e Gestione delle Aziende Sanitarie 2014/2015 Discutere il concetto di eziologia ed analizzare (per sommi capi) la storia naturale delle malattie, acute e croniche, trasmissibili e non; Discutere i principali determinanti di salute e di malattia (di natura biologica, fisica, clinica, sociale, demografica, economica, culturale, ecc.); Descrivere le tendenze globali della morbosità e della mortalità, nonché (per sommi capi) i profili epidemiologici (salute/malattia) delle principali regioni geopolitiche mondiali, europee e nazionali; Individuare e valutare i principali (sotto il profilo dell impatto epidemiologico, economico e sociale) problemi sanitari di una popolazione/comunità; Descrivere le principali tecniche (quando epidemiologiche, quando economiche) di individuazione dei rischi/opportunità per la salute umana, di analisi dei bisogni di assistenza, di valutazione delle attività sanitarie e dei loro risultati; Discutere i presupposti scientifici, economici ed etici delle decisioni sanitarie; Discutere della distinzione tra attività di tutela della salute e di produzione di prestazioni sanitarie; Fornire i presupposti scientifici e le basi metodologiche generali delle attività sanitarie (dalla promozione della salute alla prevenzione delle malattie, alle attività cliniche di diagnosi, terapia e riabilitazione); Discutere le norme generali che regolano l organizzazione sanitaria, le logiche del sistema e delle sue aziende, pubbliche o private; Far conoscere i principali aspetti strutturali, organizzativi, gestionali delle attività sanitarie (ospedaliere, territoriali, preventive) incluse le problematiche poste dalla loro integrazione; Elencare e descrivere il ruolo delle principali organizzazioni sanitarie internazionali; Far conoscere le diverse figure professionali sanitarie e le loro competenze; Far conoscere le principali risorse strutturali e tecnologiche a disposizione del sistema sanitario e la logica dell Health Technology Assessment; Leggere un piano sanitario; Impostare la programmazione di una struttura/servizio sanitari con la logica del budget collegato a precisi e misurabili obiettivi assistenziali ed organizzativi; Condurre valutazioni di qualità strutturale, dotazionale, operativa e gestionale.

3 Università di Siena CORSO DI LAUREA IN INGEGNERIA GESTIONALE C.I. Programmazione, Organizzazione e Gestione delle Aziende Sanitarie a.a. 2014/2015

4 CALENDARIO APPELLI C.I. Programmazione e Organizzazione e Gestione delle Aziende Sanitarie CL. INGEGNERIA GESTIONALE Mercoledì 24 Giugno 2015 h S.NICCOLO Mercoledì 15 Luglio 2015 h S.NICCOLO Giovedì 10 Settembre 2015 h S.MINIATO Venerdì 25 Settembre 2015 h. 09:00 S.MINIATO Giovedì 22 Ottobre 2015 h S.MINIATO Giovedì 26 Novembre 2015 h.14:00 S.MINIATO Giovedì 17 Dicembre 2015 h.14:00 S.MINIATO GLI STUDENTI SONO TENUTI AD ISCRIVERSI ONLINE. La lista sarà chiusa 48 h. prima dell appello. Prof. Nicola NANTE nicola.nante@unisi.it Dal martedì al venerdì h (su appuntamento tel. 0577/234084) Dipartimento di Medicina Molecolare e dello Sviluppo Complesso Didattico-Scientifico San Miniato Prof.ssa Cecilia QUERCIOLI c.quercioli@usl7.toscana.it; Contattabile via per appuntamenti

5 CORSO INTEGRATO Programmazione e Organizzazione e Gestione delle Aziende Sanitarie III Anno, II Semestre Contenuti: Basi di Epidemiologia e di Economia Sanitaria (MED/42) Programmazione ed organizzazione delle aziende sanitarie (MED/42) Testi di riferimento: BASI DI EPIDEMIOLOGIA E DI ECONOMIA SANITARIA L.Manzoli, P.Villari, A.Boccia - Epidemiologia e management in sanità. Elementi di metodologia, Ed. Ermes, Milano, 2008 E.Bottarelli, F.Ostanello - Epidemiologia. Teoria ed esempi, Ed.Edagricole, Milano, 2011 A. Brenna Manuale di Economia Sanitaria - CIS, Milano, 2003 PROGRAMMAZIONE ED ORGANIZZAZIONE DELLE AZIENDE SANITARIE G. Damiani, G. Ricciardi Manuale di programmazione e organizzazione sanitaria Idelson Gnocchi Editore, Napoli, 2004 N. Comodo G. Maciocco Igiene e Sanità Pubblica Ed. Carocci Faber, Roma, 2002

6 Data Ora Sede Materia Argomento Docente Mercoledì 4 marzo 2015 Mercoledì 11 marzo 2015 Mercoledì 18 marzo 2015 Mercoledì 25 marzo 2015 h Mercoledì 15 aprile 2015 h Mercoledì 22 aprile 2015 h S.Niccolò Aula F h S.Niccolò PROGRAMMAZIONE ED ORGANIZZAZIONE DELLE AZIENDE SANITARIE PROGRAMMAZIONE ED ORGANIZZAZIONE DELLE AZIENDE SANITARIE h S.Niccolò BASI DI EPIDEMIOLOGIA h S.Niccolò ORARIO DELLE LEZIONI S.Niccolò S.Niccolò PROGRAMMAZIONE ED ORGANIZZAZIONE DELLE AZIENDE SANITARIE PROGRAMMAZIONE ED ORGANIZZAZIONE DELLE AZIENDE SANITARIE BASI DI EPIDEMIOLOGIA Introduzione al Corso Integrato Storia naturale delle malattie Fattori di rischio e determinanti della salute Le fasi dell intervento sanitario I livelli di assistenza Classificazione internazionale di malattie e cause di morte Classificazione delle prestazioni sanitarie Schede di morte Schede di dimissione ospedaliera Tipi di misure epidemiologiche Mortalità e morbosità Rischio relativo, Odds ratio, rischio attribuibile Basi di Economia Sanitaria Basi di Scienze dell organizzazione L organizzazione del sistema sanitario italiano La USL Il distretto e l assistenza territoriale Gli screening I trials clinici e l Health Technology Assessment N.NANTE N.NANTE (con G.SPATARO) C.QUERCIOLI N.NANTE N.NANTE C.QUERCIOLI

7 Data Ora Sede Materia Argomento Docente Mercoledì 29 aprile 2015 h Mercoledì 6 maggio 2015 h Mercoledì 13 maggio 2015 h Mercoledì 20 maggio 2015 h Mercoledì 27 maggio 2015 h Mercoledì 3 giugno 2015 S.Niccolò S.Niccolò S.Niccolò S.Niccolò S.Niccolò h S.Niccolò ORARIO DELLE LEZIONI BASI DI EPIDEMIOLOGIA BASI DI EPIDEMIOLOGIA PROGRAMMAZIONE ED ORGANIZZAZIONE DELLE AZIENDE SANITARIE BASI DI EPIDEMIOLOGIA E DI ORGANIZZAZIONE SANITARIA BASI DI EPIDEMIOLOGIA PROGRAMMAZIONE ED ORGANIZZAZIONE DELLE AZIENDE SANITARIE Risk assessment e management Piani integrati di salute La transizione demografica ed epidemiologica del XX secolo Evoluzione strutturale funzionale dell ospedale Il personale sanitario Il dipartimento di Prevenzione Organismi sanitari internazionali Tecniche di valutazione economica applicate alle decisioni sanitarie La psicometria Il sistema informativo sanitario Obiettivi ed indicatori Dalla macro alla micro programmazione La valutazione delle performance e della qualità Discussione finale C.QUERCIOLI C.QUERCIOLI N.NANTE C.QUERCIOLI C.QUERCIOLI N.NANTE

8 DIMENSIONS OF HEALTH PHYSICAL PSYCHOLOGICAL SOCIAL

9 Public Health Set of "organized efforts of society to develop policies for public health, disease prevention, health promotion and to promote social equity in the context of sustainable development." (OMS, 1996)

10 THE CONCEPT OF HEALTH Longer life expectancy Less illness Less disability The opportunity to exercise reproductive choice (McKee, 2001)

11 Infectious Chronicdegenerative Natural History of disease Risk Factors CHRONIC DISEASE FREE PHASE PHASE OF LATENCY (INCUBATION) PRE-CLINIC PHASE OVERT DISEASE DEATH ETIOLOGICAL AGENTS HEALING

12 Natural history of the disease and possibility of intervention Healthy person (exposed to predictable risks) PRIMARY PREVENTION Elimination of causes Transmission stop Strengthening of defences Apparently healthy person (but affected by disease, asymptomatic phase, pre-clinical) Overt Disease Death Relapse risk Chronicization Complete healing Appearance of disabling outcomes SECONDARY PREVENTION TERTIARY PREVENTION Early detection Early intervention Therapy Prophylaxis of relapse Rehabilitation

13 - -

14 Health Activities : Primary prevention Diagnosis and early interventions (Secondary prevention) Diagnosis and Therapy during overt disease phase Rehabilitation

15 Aesculapius Hygieia Extraclinical - prevention - organisation Panacea Clinical Rehabilitation

16 EPIDEMIOLOGY Description of the distribution and size of the problems related to disease and illness in the human population and identification of the etiologic factors. ( O.M.S. )

17 EPIDEMIOLOGY Evaluative (needs, result) Investigative (etiology)

18 DEMOGRAPHIC STRUCTURE Pyramid chart (Ghana)

19 ITALIAN POPULATION _89 80_84 75_79 70_74 65_69 60_64 55_59 50_54 45_49 40_44 35_39 30_34 25_29 20_24 15_19 10_14 5_9 0_4 2001

20 Variation in life expectacy Neolithic Middle Ages End of XIX century 2014

21 Life expectancy at birth - Italy male female Year Year Year Year

22 LIFE EXPECTANCY IN ITALIAN REGIONS - MALE 80,00 75,00 70, ,00 60,00

23 Piemonte- Lombardia Trentino Friuli V.G. Veneto Liguria Emilia Toscana Umbria Marche Lazio Abruzzo- Campania Puglia Basilicata Calabria Sicilia Sardegna LIFE EXPECTANCY IN ITALIAN REGIONS - FEMALE 90,00 80,00 70, ,00

24 "Miracles" of Medicine

25 EVALUATIVE EPIDEMIOLOGY: some measures Morbidity Lethality Mortality

26 MORBOSITA MORBIDITY INCIDENCE INCIDENZA (measures (misura EVENTI) of events) N ammalati ( nuovi casi ) in x tempo N sicks (new cases) in x time Popolazione a rischio Population exposed X PREVALENCE PREVALENZA (measures (misura SITUAZIONI) of situations) N ammalati in un dato momento N sick at a specific point in time Popolazione a rischio momento Moment Population X

27 MORTALITY = N death in X time Risk population LETHALITY = N death in X time N sicks SURVIVAL = N alive subjects after X time from diagnosis N subjects diagnosed (sicks)

28 Incidence x Lethality = MORTALITY Primary Prevention reduces MORBIDITY Clinical Medicine reduces LETHALITY

29 Rates of incidence, prevalence and mortality observed for female breast cancer, by age group, in the city of Siena (years '92-'94)

30 mortality/1000 live births INFANT MORTALITY IN THE WORLD Industrialized Paesi industrializzati countries Africa Sub-Saharan sub-sahariana Africa America Latin America Latina Europa Eastern Europe dell'est year

31 Number of deaths in the first year of life / 1,000 live births N di morti nel 1 anno di vita/1000 nati vivi vivi Quotient of infant mortality in Italy

32 Number N of morti deaths su 1000 for 1000 residenti residents Standardized mortality for ICD9 chapters Period ,50 4,00 3,50 3,00 2,50 2,00 1,50 1,00 0,50 SIENA MASCHI Siena Male Siena Female Italy Male Italy Female SIENA FEMMINE ITALIA MASCHI ITALIA FEMMINE 0,00 Pelle Osteomuscolare Perinatale Malformazioni congenite Sangue Infettive Sintomi mal definiti Disturbi psichici Genitourinario Sistema nervoso Endocrine Digerente Traumatismi Respiratorio Tumori Circolatorio

33 N YPLL for 1000 residents Standardized rates of years of potential life lost (YPLL lifex) Period ,00 25,00 20,00 15,00 10,00 5,00 Siena Male Siena Female Italy Male Italy Female SIENA MASCHI SIENA FEMMINE ITALIA MASCHI ITALIA FEMMINE 0,00 Pelle Osteomuscolare Sangue Genitourinario Infettive Disturbi psichici Sistema nervoso Sintomi mal definiti Malformazioni congenite Respiratorio Perinatale Endocrine Digerente Circolatorio Traumatismi Tumori

34 N YPLL for 1000 residents Standardized rates of years of potential life lost (YPLL 65) Period ,00 10,00 8,00 6,00 4,00 2,00 Siena Male Siena Female Italy Male Italy Female SIENA MASCHI SIENA FEMMINE ITALIA MASCHI ITALIA FEMMINE 0,00 Pelle Osteomuscolare Genitourinario Sangue Infettive Respiratorio Disturbi psichici Sistema nervoso Sintomi mal definiti Endocrine Malformazioni congenite Digerente Perinatale Circolatorio Tumori Traumatismi

35 DEFINITION OF HEALTH SISTEM SET OF RESOURCES, ORGANIZATIONS, INSTITUTIONS dedicated to 1. PROTECT THE HEALTH OF CITIZEN 2. PRODUCE HEALTH SERVICES (O.M.S., 2000)

36

37 RESOURCES NOT ONLY MONETARY

38 ECONOMY STUDIES THE CHOICES IN CONDITIONS OF SCARCITY OF RESOURCES

39 Resources Physical spaces Staff Technology Economic Time Etc. ( R. Vaccani, 2013 )

40 TO CHOOSE (which wishes can be fulfilled and how much?) = PREFER AN ALTERNATIVE = EXCLUDE THE OTHER ALTERNATIVES

41

42 ECONOMICS: definitions NEED = difference between what you feel and what would be desirable (ability to get benefit from an intervention) DEMAND = request for intervention OFFER = assistance (goods, facilities, services, and interventions) available / equipped to meet (delete) needs

43 ECONOMICS: definitions GOODS = material means of which you need to meet the needs SERVICES = performance, intangible assets that will meet the needs

44 Tecnica Ospedaliera, Maggio 2013

45 TO CONSUME To satisfy a need through a benefit (or a service)

46 MARKET Place where demand and offer meet halfway, if there is free competition, and where there is the best equilibrium quality/price (LIBERISM)

47 ASSUMPTION OF THE EXCHANGE There may be BARTER when there is coincidence/contemporaneity of the The MERCHANT brings together the needs of who wants a good and who owns/wants to sell it The role of BANKS is to bring together people needs

48 Characteristics of exchange goods Small and constant dimension Not perishability(non deperibilità) Maintaining the value over time Considered of value to many people

49 GOLD COIN FIDUCIARY MONEY BILL OF EXCHANGE PAPER MONEY BITCOIN

50 Economy Actors Who owns Who plays Who organize (creativity)

51 Specialization of tasks Capitalist Owns production means Entrepreneur Management Creativity Worker Produce with his own hands Income Profit Wage

52 SOCIALISM Production means and business belongs to the State State decides how much and what to produce

53 Only one producer Only one buyer A lot of buyers A lot of producers

54 Information asymmetry (who pays does not have adequate information on the good he pays for) Patients decisional inability in emergency cases The need is not expressed by the consumer but from an intermediary/agent (the physician), with unavoidable distortions Difficulties in defining (quantification and valuation) the product health/healing The need tends to infinty (eg. Drugs against elder people impotence) Health is a primary good (da L.Manzoli, 2008, modificata)

55 PATIENT (potential user) PHYSICIAN (Agent) PROGRAMMER PRODUCER OF PERFORMANCE Perceived Expressed Appropriate Satisfied need NEED DEMAND OFFER not perceived not expressed useless Improper performance; wasteful

56 OBJECTIVE OF HEALTH PLANNING N N-D D TO COINCIDE: NEED DEMAND OFFER N-D-O N-O D-O O N D O

57 ALTERATION OF THE RELATIONSHIP N-D-O Improper demand in shortage of supply (organ transplants, waiting lists) Need not perceived(eg prevention) Perceived need But not expressed in demand (eg self-diagnosis) N N-D N-D-O N-O D-O D Improper demand (risk of inducing offer) (request check-up) O Improper offer (risk of induction of the demand) (advertising, excess p-l)

58 CLASS OF DECISIONS Strategic choices (Politic, Property) Directional choices (Manager, Director) Operating choices (Line operator)

59 Lab. Programmazione ed Organizzazione dei Servizi Sanitari - Università di Siena Allocation Linkage Bargaining OBJECTIVES RESOURCES

60 PROGRAMMAZIONE SANITARIA P.S.N. REGIONE P.S.R. RELAZIONI CONSUNTIVE P.A.A. BUDGET

61 PIANIFICAZIONE (planning) Planning is a decision-making activity, a political before than a technical process; through planning, starting from the analysis of the situation (health needs), some health protection general targets are expected to be pursued, and some actions are expected to be done (sanitary strategies)

62 PROGRAMMAZIONE (scheduling) Scheduling brings the project from an ideal to a concrete plan; it defines times and deadlines, it gives roles and tasks to optimize skills and resources, and it empower human resources that are involved in the main objectives.

63 PLANNING = Decidere di far fare SCHEDULING = Decidere di fare

64 STRATEGY general objectives TACTICS intermediate objectives MANAGEMENT Specific objectives PLAN (strategic) PROGRAM (analitic) PROJECTS (operating) Long term Medium term Short term

65 Scientific assumptions of Health Planning EPIDEMIOLOGY ECONOMICS SOCIOLOGY

66 The main goal of social and health planning is answering to a certain need or discomfort.

67 PLANNING SITUATION (PROBLEMS) STRATEGY (OBJIECTIVES) INTERVENTION (ACTIONS)

68 A social-sanitary plan it s a prescriptions system: in health politic: In health strategy Health promotion Equity Accessibility Social aspects Prevention Early diagnosis Care Rehab in organizational strategy Institutional/structural/organizational intervention Informative System/research Training in resources allocation: Current resources Investment resources

69 The budget characteristics Derived from the company's strategic plan by providing an annual declination Expressed in financial terms the objectives that the company intends to achieve in the next period (objectives - decisions - resources) It is related to the company in its entirety (globality) It is organized by responsibility centers It is reported in sub-annual intervals

70 Budget functions Guiding and directing the actions of managers and business managers, assigning appropriate resources and allowing the ex-ante coordination of their actions Verify the feasibility of the plan, in the light of short-term constraints Provide financial parameters necessary for the comparison targets-results (see feedback mechanism): the budget is a tool for implementation of the plan and its control (including operational) Motivate employees and managers to achieve the objectives Allow the evaluation of the performance and behavior

71 ORGANIZATION System of men, equipment and capital somehow interdependent, having a common goal

72 ORGANIZATION = WORKING TOGETHER (F. Di Stanislao)

73 Relationships between operators of a team L C Independence Cooperation Coordination Leadership

74 The value of the necklace are not the pearls that make it up, but in the thread that holds them together Confucius

75 A) Hierarchical Organization Manager B) Matrix organization Manager U.O.3 U.O.1 U.O.2 U.O.4 U.O.5 Project 1 Project 2 Project 3

76 Basic parts of an organization Strategic summit Technostructure Intermediate line Support staff Operational core (Mintzberg, 1979)

77 Production Factors Process Intermediate product Final result input throughput output outcome Planning and external factors Reports Performance SDO Invoices Health gain Decreased risk Side Effects

78 SYSTEMIC ANALYSIS OF AN ORGANIZATION INPUT (Factors) OUTPUT (Goods/Services) Financial resources Raw materials (Patients) Labor market Technology Scientific research Laws and regulation Social values Informations Needs (demand) Risks Energy Etc. Basic Structure (Architecture) Operating mechanisms (Rules) Social Processes Prevention Diagnostic Care Rehabilitation TROUGHPUT (Elaboration process, Dynamic interdependencies) The R.Vaccani s candy,2001

79 Free Administered OFFER OF HEALTH GOODS AND SERVICES Free in nature For Benevolence, kinship, voluntary Free at the time of fruition Private insurance Charged to Mutual insurance Taxation With price ACCESS RULES Market

80 MISSION of the health service To ensure, through the promotion of useful initiatives and the provision of appropriate health services, with an acceptable cost to the community, a better quality of life, socially and professionally more active and long to the largest number of people possible

81 HEALTH SYSTEMS INDIVIDUALISTIC (optional membership) SOLIDARISTIC (mandatory contribution)

82 TIPOLOGIE DI SISTEMI SANITARI IN PAESI SOCIALMENTE AVANZATI Modello Nazione Organismo di protezione BEVERIDGE GRAN BRETAGNA % di popolazione coperta Accesso alla protezione Requisiti Finanziamento prevalente Servizio Sanitario Nazionale 100% Automatico Residenza Sistema tributario Tipo di protezione Tutela salute in toto ITALIA Assicurazioni malattia sociali 90% GERMANIA Assicurazioni private 7.5% BISMARK Assicurazioni sociali + private 6.7% Obbligatorio Volontario Professione Contributi sociali Prestazioni di diagnosi, cura e riabilitazione * FRANCIA Assicurazione sociale malattia di base 99% Mutue integrative 69.3% Assicurazioni private e mutualistiche Variabile secondo le cure Volontario Professioni ed altri Organi federali: LIBERO MERCATO STATI UNITI - Medicare 12% Automatico Più di 65 anni - Medicaid 9% Automatico Povertà Premi di assicurazione Prestazioni di diagnosi, cura e riabilitazione * Senza assicurazione 12.6% SVIZZERA Assicurazioni private e mutualistiche 97% Volontario Professioni ed altri Premi assicurativi + fondi pubblici * le attività di prevenzione sono assicurate da altri organismi statali finanziati dal sistema tributario generale

83 THE ITALIAN HEALTH SYSTEM ANTE 833/78 Public Health Hospitals Mutual associations

84 THE NATIONAL HEALTH SERVICE (and the Local Health Unit) COLLECTIVE PREVENTION (prevention departments) HOSPITAL CARE (hospitals) COMMUNITY CARE (basic health districts)

85 Basic principles of universalistic welfare universality of the recipients access to health services is not subject to "social" eligibility criteria nor of availability of funds, but only to the professional judgment of the need for assistance (elimination of economic and social barriers, through the tendency gratuitous consumption) equality in access to uniformly distributed services elimination of geographical barriers to access, guaranteed by the local planning of services (uniform distribution of the offer) broad spectrum of interventions tendency totality of assistance levels equality of treatment outcome sharing of financial risk the individual contribution is independent of the risk of illness and services received but determined solely by the ability to pay tax participation of citizens in decisions vote and choices

86 Legge 23/12/1978, n 833 INSTITUTION OF THE NATIONAL HEALTH SERVICE Art. 1- Principles The Republic safeguards health as a fundamental right of the individual and collective interest by the National Health Service... The National Health Service shall comprise all of the functions, facilities, services and activities for the promotion, maintenance and recovery of physical and mental health of the entire population, regardless of individual or social conditions and in a manner that will ensure equality of citizens...

87 ASSURANCES DISPENSERS CITIZENS / PATIENTS

88 Costituzione della Repubblica Italiana Art. 32 La Repubblica tutela la salute come fondamentale diritto dell individuo e interesse della collettività e garantisce cure gratuite agli indigenti. Art. 32 The Republic safeguards health as a fundamental right of individual and collective interest, and guarantees free medical care to the needy...

89 Legge 23/12/1978, n 833 INTRODUCTION OF THE NATIONAL HEALTH SERVICE Art. 10- The territorial organization The management of health protection shall evenly throughout the country through a comprehensive network of Local Health Units. The Local Health Unit is the set of garrison, offices and services of Commons (individual or group) and the Rural Communities, which, in certain geographical area, perform the tasks of the National Health Service...

90 The territorial scope of activities of each USL is bordered on the basis of population groups as a rule between 50,000 and 200,000 inhabitants, considering the socio-economic and geomorphological characteristics of the area. In the case of areas of population particularly concentrated or spread and in order to allow the coincidence with a municipal area, higher limits are permitted, or in special cases, smaller... TERRITORIAL AREA OF U.S.L. The territorial scope of the Local Health Unit usually coincides with the one of the province. In relation with particular territorial conditions, especially in rural areas, and with the density and distribution of population, the region provides geographical areas of different extensions Legge 23/12/1978, n 833 ISTITUZIONE DEL SERVIZIO SANITARIO NAZIONALE DD.LL n 502/92 e 517/93 RIORDINO DELLA DISCIPLINA IN MATERIA SANITARIA

91 DETERMINING THE TERRITORIAL SCOPE OF THE ASL CRITERIA AIMS Density and distribution of population Geomorphological characteristics of the area Equity of access Socio-economic characteristics Historical, cultural and political ties Efficiency Participatory opportunities Financial sustainability (combination of input) Epidemiology Effectiveness

92 Le USL del Servizio Sanitario Nazionale

93 FUNZIONAMENTO DEL S.S.N. LIVELS ORGANS ACTIVITIES CENTRAL Parliament Ministry of Health Regional State Conference - Laws - National Health Plan - Actions to direct REGIONAL Region Region Region - Regional Laws - Regional Health Plan LOCAL U.S.L. A.O. U.S.L. A.O. - Implementation plan business - D.G. decisions OPERATIVE District Hospitals Prevention Department - Services and performances

94 Legge 23/12/1978, n 833 INTRODUCTION OF THE NATIONAL HEALTH SERVICE Art. 14- The Local Health Unit provides : health education individual and collective prevention of physical and mental illnesses the health protection of mother and child, pediatric care and protection of the right to conscientious and responsible procreation medicine and hygiene education in institutions of public and private education hygiene and occupational medicine, and the prevention of occupational accidents and occupational diseases sports medicine and health protection of sporting activities; medical care and general nursing home care for physical illnesses and psychic hospital care for physical and mental illnesses rehabilitation pharmaceutical care and supervision of pharmacy hygiene of the production, processing, distribution and sale of food and beverages prevention or animal health, the veterinary inspection and supervision on animals intended for human consumption, on slaughterhouses and processing, food of animal origin, livestock nutrition and communicable diseases from animals to humans, reproduction, breeding and animal health, drug use veterinary assessments, certifications...

95 THE INSTITUTIONAL OVERSEEN ENTITIES (HELPING HEALTH MINISTRY) Consiglio Superiore di Sanità (CSS) Istituto Superiore di Sanità (ISS) Istituto Superiore per la Prevenzione e Sicurezza del Lavoro (ISPESL) Agenzia Nazionale per i Servizi Sanitari Regionali (AGENAS) Istituti Zooprofilattici Sperimentali (IZS) Agenzia Italiana del Farmaco (AIFA) Croce Rossa Italiana (CRI)

96 Piano Sanitario Nazionale ESSENTIAL LEVELS OF ASSISTANCE The levels of health care define the guarantees that the NHS undertakes to ensure to the citizens, in order to achieve consistency between the overall objective of protecting health and the funding available. They are called essential levels of assistance, as needed (to meet the basic needs of promotion, maintenance and recovery of health conditions of the population) and appropriate (with respect to the specific health needs of the citizen and the procedures for payment of benefits), must be uniformly guaranteed throughout the national territory and to the community, taking into account differences in the distribution of care needs and the risks to health.

97 LEVELS (forme - aree) Uniform Minimum Guaranteed Obligatory Federal Essential Possible OF ASSISTANCE

98 Essential Levels of Assistance AREAS OFFER ALLOCATED RESOURCES Collective health care (prevention) 5 % District Assistance 49,5 % Hospital care 45,5 % Performance certainly excluded: 1. NOT RELEVANT 2. NOT EFFECTIVE AND INAPPROPRIATE 3. DO NOT COST - EFFECTIVENESS

99 UNIFORM LEVELS OF ASSISTANCE 1) Health care in collective living and working environment - Prophylaxis of infectious and contagious diseases - Protection of the risks associated with environmental pollution - Protection of the risks associated with living and working environments - Veterinary Public Health - Protection of health and hygiene of food 2) District assistance - Basic Health Care - Pharmaceutical care - Outpatient specialist care - Semi-residential and community care - Residential care health 3) Hospital care - Acute care (emergency, routine and day hospital) - Post-acute care (routine and day hospital rehabilitation and long-term care)

100 DEFINITION OF THE LEVELS OF HEALTH CARE The D.P.R. December 24, 1992 try in italian way (in the sense of leave, where possible, to others the responsibility for the choices) to mediate the two irreconcilable demands of health planning: define if the National Health Fund from health needs to be met (which goes attributed the failure to set the parameters of capitation funding for individual levels) or from within the resources available. ( QRSS, ottobre 93)

101 USL PREVENTION DEPARTMENT DISTRICT HOSPITALS ADMINISTRATION AND CENTRAL SERVICES Internal Services: External services : Food hygiene and nutrition Prevention and safety workplace Hygiene and Public Health Diagnostic laboratories outside the hospital Outpatient clinics and counseling centers(*) Residential Care Health (Homes for the elderly, etc.). Home care In Convention : -General practitioners and doctor on call - Pharmacies Accredited : -Medical specialists outside -Autonomous public hospitals -Private clinics and thermal companies -Diagnostic laboratories outside -Centers re-education and assistance residential health Inpatient wards Operating rooms Diagnostic laboratories Emergency department Superintendency Treasurer Pharmaceutical and General Stores Staff administration Veterinary Services Administration and General Services (*) Family, SERT, geriatric, etc.. Administration and General Services Accounting and other functions of the central administration

102 D.L. 19 giugno 1999 n 229 RULES FOR RATIONALISING S.S.N. DISTRICT Articulation Local Health Unit that assists a population of at least sixty thousand inhabitants (except geomorphological features of the area or low density of residents). The district shall provide the services of primary health care and integration of health on social care.

103 The district provides: D.L. 19 giugno 1999 n RULES FOR RATIONALISING S.S.N. FUNCTION OF THE DISTRICT primary care, including continuity of care, through the necessary coordination and multidisciplinary approach in the clinic and at home, including general practitioners, pediatricians, doctor on call services and festive nightlife and principals specialist outpatient; the coordination of general practitioners and paediatricians with the Deans Hospital and operational structures to direct management or credited; the provision of health services of social importance, as well as the social benefits of sanitary importance if delegated by the municipalities; prevention and health education. The district gives: outpatient specialist care; activities or services for the prevention and treatment of drug addiction; activities or counseling services for the protection of the health of children, women and the family; activities or services for the disabled and elderly; activities or services of integrated home care; activities or services for HIV disease and diseases in the the terminal stage They are also functional position in the district organizational units of the Department of Mental Health and the Department of Prevention, with particular reference to personal services.

104 Family medicine or base is the key element of primary care and the direct point of contact between the citizen / user and health services. It ensures: -General (address all the problems) -Continuity (not limited to individual episodes of illness) -Globality (integrated service, prevention, health promotion, care, rehabilitation and physical support -Coordination (among other specialized services) -Collaboration (with other health and social workers involved in the therapeutic process) -Contextualization within the family -Orientation to the community (socio-epidemiological contextualization)

105 MEDICO DI MEDICINA GENERALE

106 A.F.T. Mono-professional functional aggregation replaces the single physician (adhesion required) attended (at least 20 doctors) all GPs in a geographical area U.C.C.P. aggregation structural multiprofessional (concentrated in center-house of health) GPs nursing staff auxiliary staff medical specialists Medical technicians (only diagnosis?) Health and social care

107 da Dir.Amm. Proiezioni da e verso altri livelli assistenziali ASSISTENZA PRIMARIA E SOCIOSANITARIA Distretto 1 Distretto 2 Distretto 3 Program.orgganiz.valutaz. dei serv. sanitari territoriali organizzazione valutazione e controllo organizzazione valutazione e controllo Unità di cure primarie MMG Unità di cure primarie MMG Unità di cure primarie MMG Specialistica Ambulatoriale Specialistica Ambulatoriale Specialistica Ambulatoriale DIPARTIMENTO CURE PRIMARIE Riabilitazione e Protesica Riabilitazione e Protesica Riabilitazione e Protesica Assistenza Domiciliare Assistenza Domiciliare Assistenza Domiciliare Strutture Residenziali Strutture Residenziali Strutture Residenziali DIPARTIMENTO URGENZA ED EMERGENZA DIPARTIMENTO MATERNO-INFANTILE Consultori Unità di Pediatria di Base Consultori Consultori Consultori Consultori DIPARTIMENTO SALUTE MENTALE E DIPENDENZE C.S.M. SERT SERT SERT SERT SERT DIPARTIMENTO ATTIVITÀ AMMINISTRATIVA

108 D.Lgs 19 giugno 1999 n 229 RULES FOR RATIONALISING S.S.N. SOCIAL AND HEALTH SERVICES Activities to meet, through integrated care pathways, individual health needs that require a unified health care and social protection measures can ensure, in the long term, the continuity between the actions of those in care and rehabilitation. INCLUDE: a) health care by social relevance, that is, activities aimed at health promotion, detection, removal and containment of degenerative or debilitating outcomes of congenital and acquired (the responsibility of the ASL); b) performance-relevant health, namely the activities of the social system whose objective is to support the person in need, with issues of marginalization conditioning disability or health status (the responsibility of the municipalities).

109 PREVENTION DEPARTMENT Operating structure that ensures the protection of public health, pursuing goals of health promotion, prevention of disease and disability, improve quality of life. Promotes actions to identify and remove the causes of disease and harm to environmental, human and animal, through initiatives coordinated with the Districts, with other local health departments and hospitals, providing for the involvement of professionals from different disciplines.

110 Prevention Department Functions Prophylaxis of parasitic infections Protect the community from health risks of living environments Protect the community and the individuals in the workplace Veterinary Public Health Hygiene of food Nutritional surveillance and prevention

111

112 HOSPITAL The hospital is an localized institution, deputy to the production of diagnostic and therapeutic services of intensive / invasive / complex type

113

114 .GLI OSPEDALI IN ITALIA SONO BEN PROVVEDUTI, HANNO SPLENDIDE SEDI, FORNISCONO CIBO E BEVANDE OTTIME, IL PERSONALE È ASSAI DILIGENTE E I MEDICI DOTTISSIMI. APPENA ENTRA UN INFERMO, QUESTI DEPONE IL VESTIARIO E QUANTO ALTRO GLI APPARTIENE; DI TUTTO VIENE PRESO NOTA PER UN ACCURATA CUSTODIA. POI L INFERMO INDOSSA UN CAMICE BIANCO E GLI VIENE APPRESTATO UN BUON LETTO CON BIANCHERIA DI BUCATO. SUBITO DOPO SOPRAGGIUNGONO DUE MEDICI ED INSERVIENTE CHE PORTANO CIBO E BEVANDE, CONTENUTI IN VASI DIVERSI, CHE NON VENGONO TOCCATI NEMMENO CON UN DITO, MA PRESENTATI SOPRA VASSOI. ANCHE MATRONE VELATE SERVONO GLI INFERMI PER ALCUNI GIORNI, QUINDI, NON CONOSCIUTE, TORNANO ALLE LORO CASE. Martin Lutero, 1511

115 HOSPITAL: functional evolution TEMPLES (asclepiei) MILITARY INFIRMARIES (valetudinaria) HOUSING AND PRIVATE PRACTICE(iatrei) XENODOCHY, BREPHOTROPHĪUM (religious orders of chivalry, lay) QUARANTINE HOSPITALS, LEPER COLONIES HOSPITALS

116 HOSPITAL: structural evolution cross plate monoblock enclosed courtyard modulate pavilions plate

117 HOSPITALS: Essential components / functions HOSPITAL WARDS - medicine, surgery, pediatrics, infectious diseases, obstetrics, etc.. - high / medium / low intensity of care SPECIAL SERVICES FOR DIAGNOSIS AND TREATMENT (clinic, emergency department, operating rooms, laboratory analysis, radiology, pathological anatomy, hemodialysis, radiotherapy, ecc.) GENERAL SUPPORT SERVICES (health, technical, hotel) ADMINISTRATIVE SERVICES

118 Hospital care DOMINIUM Core Intensive cure INTENSITY High Emergency Department Special Services Medicine Surgery Maternity Pediatrics Infectious diseases Diurnal Cycle Average Clinics Low level inpatient care Territory Home hospitalization Low

119 VENEZIA, 1605 da Cirurgia Universale e perfetta di tutte le parti pertinenti all ottimo Chirurgo di G.A. Dalla Croce (web.genie.it/utenti/f/fappto/pubb/infnoss8.htm)

120

121 hospitals AUSL Privates Insurances services managed by AUSL private services

122 - -

123 ITALIAN HEALTH SYSTEM Planning (Emilia Romagna, Toscana) Regional models Competition (Lombardia) Mixed (Piemonte, Liguria, Lazio) Late responders (Sicilia, Sardegna, Campania)

124

125

126

127 Situation Analysis (Identify situations substandard Identifying the causes Identify the remedies Put them in order of priority importance, feasibility) Lab. Programmazione ed Organizzazione dei Servizi Sanitari - Università di Siena Evaluation (Implement reward systems) Planning (Fixing macro-objectives, Allocation of financial resources) Management (Operational steps, Checking in progress) Programming (Definition of micro-objectives, Allocation of financial resources) Organization (Combination / relationships between resources)

128 CHOOSE (which wishes can be fulfilled and to what extent) = PREFERING AN ALTERNATIVE = EXCLUDING OTHER ALTERNATIVES

129 COMPANY STRUCTURE Technical : Human: Structures Plant and equipment logistics Processes production processes distribution processes things activity Professionalism (skills) Dividing tasks and functions Responsibility, authority Links Authority Communication Systems Evaluation, reward systems

130 Human Resources Skills (knowledge validated "by profession") Attitudes (individual personality traits) ( R. Vaccani ; 2013 )

131 COMPANY STRUCTURE Strategic summit Intermediate Management Operational core Volitional institutional o. (properties) Executive o. (transforms objectives into programs of action) Advisory o. (tecnostructure of staff or external consultants) Control o. (Internal / External) Executive and operational o. (transformation of inputs into outputs)

132 Organs of the structure CONTINUOUS DISCONTINUOUS PERMANENT Direction Assembly of members Board of Directors Board of Auditors TEMPORARY Project team Committees Study groups

133 Social Processes Flexibility, Creativity (ability to deal with the unexpected and opportunities) Acceptance (consent, identification) Rejection (Dissent towards new structural elements or process, etc.). Compensation (Discretionary Behaviors of "supplementary organizational") Ecc. ( R. Vaccani, 2013 )

134 Tools of organizational formalization Organization Charts Staffing plan Descriptions of the attributions Regulations

135 ORGANIZATION Goals / Tasks Preservation system / group Individual needs

136 Organizational Change FOR DISCONTINUITY (restructuring and rising) INCREMENTAL (improvements in the process, participated, shared) ( R. Vaccani ; 2013 )

137 The caterpillar syndrome on the leaf Typical defect of all specialized professions that to study the leaf they end up thinking that the world exists only his ribbing

138 MACRO ENVIRONMENT Political factors OPERATING ENVIRONMENT Customers International factors Social Interest Groups Competitors INTERNAL ENVIRONMENT Structure Technology Staff Culture Policies Suppliers Standardization bodies Economic factors factors Technological factors

139 The driving force of every human action is the motivation that, in a more or less conscious, determines choices and behaviors

140 The Maslow's value scale Self-realization Physiological Hunger, thirst, sleep sex Safety Protection from dangers, threats and deprivations; appropriation of their territory Membership Sociability, affection, friendship, acceptance, love, social groups Esteem Self-esteem: self-confidence, independence, achievement; Esteem of others, status, recognition, respect deserved by colleagues Develop their skills, and constantly develop themselves

141 THE HERZBERG's REWARD SYSTEM a) Hygiene factors or "maintaining"(satisfying) Relate to the corporate objective context in which the work takes place Are work's extrinsic motivators Are related to primary factors of conservation of existence Lose strength when the needs are relatively paid The force is felt especially when the needs are disappointed b) Motivating factors Relate to the subjective content of the work Are intrinsic motivators Are related to secondary needs, more advanced The motivations linked to it are not "asleep" from the satisfaction, but they are stimulated further The motivations connected with them gain strength with repeated successes, the lack of success makes them disappear

142 ( da A.Smith La ricchezza delle nazioni, 1776 )

143 MOTIVATIONS POSITIVE(awards) NEGATIVE (penalty) INFORMAL(based on the values and habits of the person) Smile Pat on the back Compliment Applause Certificate of estimate Gossip Ridiculise Sarcasm Exclusion Reprimands FORMAL (based on staff policy) Bonus Salary increase Promotion Privileges Formal recognition Fine Suspension Transfer Dismissal Suspension of privileges

144 REMUNERATION METHODS FOR HEALTH SERVICES Parcel payment -Suitable for standardized performance -Base pay is the single performance (more or less complex) -Risk of increased performance Capitation -Assumes the identity of the average annual workload entailed by homogeneous groups of patients -Base remuneration is borne by the number of patients (for all and some performance) -Risk of decrease performance Salary - With bonds of subordination (suits to cases in which the required performance are composite and heterogeneous) -Base pay is the time -Risk of bureaucratization Achieved objective (so-called pay "on result ) - In private relationships is forbidden by the code of professional ethics

145 Types of power relationships in consulting TYPE SOCIAL POWER MEDICAL AUTHORITY CONSULTATION DYNAMICS aristocratic Patient: very strong Doctor: very weak Individual The patient may attack the professional private Patient: medium individual refined Doctor: medium bureaucratic Patient: weak office (we think) for the most educated Doctor: strong charity Patient: very weak office the practitioner can attack the patient Doctor: very strong

146 HEALTH SERVICE QUALITY THE 3 E Effectiveness Efficiency Equality

147 HEALTH INDICATOR measure of health status or healthrelated characteristic (eg. resources of the health system, personal behaviors, environmental factors, etc..) that is used in the planning and evaluation of a program

148 N.H.S. INDICATORS (D.Lgs. 502/92) ex art. 10 efficiency and quality (D.M. 24 luglio 1995) TECHNICAL QUALITY ex art. 14 humanization, hotel services (D.M. 15 ottobre 1996) PERCEIVED QUALITY

149 BUSINESS INDICATORS STATE PROCESS OUTCOME - Need - Demand - Resources - Accessibility - activities - products - Desired result - Debt normed (?) - Side effects (positive, negative) Definition of objectives Allocation of resources Efficiency ratings Evaluation of effectiveness economic analysis(cm, ce, cu, cb)

150 NEEDS OF HEALTH P E R T I N E N C E OBJECTIVES OF HEALTH RESOURCES -Spaces -Staff -Equipment - EFFECTIVENESS PRODUCTION SYSTEM PROCESS PERFORMANCE -Quantity -Quality RESULTS IN TERMS OF HEALTH EFFICIENCY PRODUCTIVITY

151 HEALTH INFORMATION SYSTEM - Data routine - Data collected ad hoc

152 Health Service Research Laboratory ASSESSMENT TOOLS FOR HOSPITAL PROCESS - Quality of the medical record - Appropriateness of hospitalization and inpatient days - Times of diagnostic investigations - Prevalence / Incidence of nosocomial infections

153 OUTCOMES -Clinici (hard) -Subjective health state (soft) satisfaction - Economic and financial

154 AMERICA S BEST HOSPITALS Benchmarks for Success Performances Measures Risk-adjusted mortality index Risk-adjusted complications index Quality of care Severity-adjusted average length of stay Index of total facility occupancy Productivity (total asset turnover ratio) Index of outpatients activity Expense per case mix-and wage-adjusted discharge Profitability (cash flow margin) Long-term growth in equity Charge per adjusted discharge Efficiency Final results Value for the customer

155

156 ANALYSIS OF SATISFACTION AND DISSERVICE THROUGH INTERVIEWS WITH PATIENTS / CLIENTS Reporting ability Rating ability 1) Ability to report facts and data relevant for evaluation of the service 2) Patient's ability to make judgment

157 ATTIVITA' FISICA RUOLO FISICO DOLORE FISICO SALUTE GENERALE VITALITA' FUNZIONALITA' SOCIALE RUOLO EMOZIONALE SALUTE MENTALE PROFILI DI SALUTE (Indagini condotte con SF-36) PROFISALUTE SF-36: traccia il tuo profilo di salute POPOL. ITALIANA > 18 aa (1995) POPOL. ITALIANA > 75 aa (1995) MONTERONI D'ARBIA > 75 aa (1997) Using the SF-36 in a rural population of elderly in Italy a pilot study Nante N., Groth N., Guerrini M., Galeazzi M., Kodraliu G., Apolone G. (J. Prev. Med. Hyg., 1999)

158 IL RILIEVO PASSIVO

159 I PAZIENTI VOTANO CON I PIEDI (Tiebout, 1956)

160 GOODS Tangible Intangible

161 TO CONSUME Meeting a need through a good (or a service)

162 REGIONE STATO IRAP IRPEF (%) IVA (%) Fondo di compensazione Contributi statali straordinari REGIONE Quota capitaria ASL Budget Budget Giornata di degenza Fee for service DRG* DRG* Lungodegenza Prevenzione Emergenza Ambulatoriale Day Hospital Presidi Ospedalieri * Con diverse forme di compensazione (tetti di spesa) e tariffe modulate (da L. Manzoli, 2008, modificata) e cliniche private