Nurses

• Registered Nurses - real nurses

• LPN - licensed practical nurses

• Nurse Practitioners

• non-licensed caregivers

Nurse-Patient Relationship

• Nurses are independently licensed

• Nurses have an independent duty to patients

• Nurses exercise independent judgment

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

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

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

Nurse Extenders

• lower level care providers

• medical assistants, surgery technicians, lab technicians

• on the job training vs certification

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

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

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

STRUCTURE OF HEALTH SYSTEMS

20 February 2009

WHAT IS HEALTH ?

• A STATE OF COMPLETE PHYSICAL, MENTAL AND SOCIAL WELL-BEING, NOT MERELY THE ABSENCE OF DISEASE

• WORLD HEALTH ORGANIZATION

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

PUBLIC HEALTH VS PERSONAL HEALTH

• PUBLIC HEALTH - TO IMPROVE THE HEALTH OF A POPULATION

• PERSONAL HEALTH - TO IMPROVE THE HEALTH OF THE INDIVIDUAL

US PUBLIC HEALTH SYSTEM

• Local System – very political

• Governed by Boards of Health

• Health Officer/Director

HEALTH DEPARTMENTS

• Environmental Management– Vectors– Water quality– nuisances

• Disease Control– Clinics– Epidemiology

• Personal Health Services

PREVENTION

• PRIMARY - PREVENTION OF DISEASE

• SECONDARY - PREVENTION OF CONSEQUENCES OF DISEASE

• TERTIARY - PREVENTION OF DEATH OR DISABILITY

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

INTEGRATED ORGANIZATIONS

• HOSPITALS, PHYSICIANS, INSURERS, AND PURCHASERS FORM VERTICALLY AND HORIZONTALLY INTEGRATED ORGANIZATIONS

• IN OTHER CONTEXTS THESE ARE CALLED MONOPOLIES

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

VERTICAL INTEGRATION

• LINKING ORGANIZATIONS SO THAT SUCCEDING TRANSACTIONS STAY WITHIN THE SYSTEM

• MEDICAL EXAMPLE– OCHSNER CLINIC

• MONOPOLY EXAMPLE– STANDARD OIL

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

TRIAD OF GOVERNANCE

• Governing Body

• CEO

• Professional Staff Organization

Hospital Medical Staff

• Bylaws are the structure– Not like corporate bylaws

• Licensed Independent Practitioners– Their contract with the hospital

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

Credentialing

• Prove training and experience

• National Practitioner Data Bank

• Major liability for the hospital

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

Management Skills

• There is special training for healthcare administration

• Getting an MD or a BSN does not make you too stupid to learn this