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ORGANIZATIONALORGANIZATIONALASPECTSASPECTS
DR. JUAN BATLLEDR. JUAN BATLLE
HOSPITAL DR. ELIAS SANTANA
Santo Domingo, Rep. Dominicana
CLEAR GOALS
IF YOU DO NOT HAVE A PLAN, YOU CAN PLAN TO FAIL.
ITEMS TO BE DISCUSSED
A. IDENTIFICATION OF NEED
B. QUANTIFICATION OF RESOURCES
C. SELECTION OF ADMINISTRATIVE CULTURE
D. IMPLEMENTATION OF RESOURCES
E. SELF-EVALUATION
F. VISION OF FUTURE
IDENTIFYING NEED
NATIONAL INVESTIGATIONS POPULATION CENSUS PUBLISHED STUDIES OF
BLINDNESS PREVALENCE OF BLINDNESS
BETWEEN 0.4% & 0.6% HALF OF THE BLIND CASES
SUFFER WITH CATARACTS
HOW MANY BLIND PEOPLE EXIST IN LATIN AMERICA?
THERE ARE FEW INVESTIGATIONS AND NO CENSUS 1987 IN THE CENSUS OF OMS: 1,760,000 MINIMUM
2,760,000 MAXIMUM
TOTAL POPULATION: 397,000,000 HALF OF THEM SUFFER FROM CATARACTS IN A POP. OF 400 MILLION INHABITANTS IN LATIN
AMERICA, SOME 2 MILLION ARE BLIND IN BOTH EYES
APPROXIMATELY 1 MILLION ARE BLIND BECAUSE OF CATARACTS
PREVENTION OF BLINDNESSCENTRAL AMERICACOUNTRY POPULATION PREVALENCE
MEXICO 79,000,000 500,000-1,00,000
GUATEMALA 8,000,000 30,000-50,000
HAITI 6,000,000 30,000-50,000
DOMINICAN REPUBLIC
8,000,000 30,000-50,000 (33,000)
JAMAICA 2,500,000 5,000-10,000
PANAMA 2,000,000 5,000-10,000
EL SALVADOR 5,000,000 15,000-25,000
CUBA 10,000,000 30,000-50,000
COSTA RICA 3,000,000 10,000-15,000
HONDURAS 5,000,000 20,000-35,000
NICARAGUA 4,000,000 15,000-25,000
PREVENTION OF BLINDNESS IN S. AMERICA
COUNTRY POPULATION PREVALENCE
BRASIL 135,000,000 500,000-1,000,000
COLOMBIA 28,000,000 100,000-150,000
PERU 20,000,000 80,000- 20,000
ECUADOR 9,000,000 35,000- 50,000
CHILE 12,000,000 40,000- 60,000
VENEZUELA 15,000,000 50,000-70,000
PARAGUAY 3,500,000 10,000-15,000
URUGUAY 31,000,000 110,000-165,000
ARGENTINA 29,000,000 100,000-150,000
BOLIVIA 8,000,000 25,000-40,000
INFANT BLINDNESSIN LATIN AMERICA
COUNTRY PERU BOLIVIA URUGUAY CHILE JAMAICA
EXAM. 405 78 155 3 esc. 100
DATE 1986 1988 1988 1986 1986
CORNEA 6 23 4 8 5
GLAUCOMA 9 10 12 16 12
RETINA 24 23 24 31 15
O.N. ATROPHY 9 10 9 7 15
OTHERS 35 13 23 34 8
Source: CBM
OPHTHALMOLOGIST/ POPULATIONCOUNTRY OPHTH. / POPULATION
HAITI 1:230,000
NICARAGUA 1:200,000
ECUADOR 1:129,000
GUATEMALA 1:111,000
COSTA RICA 1:85,000
BOLIVIA 1:76,000
BRASIL 1:67,000
R. DOMINICANA 1:56,000
COLOMBIA 1:40,000
PERU 1:27,000
BLINDNESS SURVEY IN DOM. REPUBLIC (1995)
PREVALENCE = 0.45% BLINDS PRINCIPAL CAUSE = 46% CATARACT SECOND CAUSE = 22. 5% GLAUCOMA OUT OF A POPULATION OF 7.5
MILLION, 16,570 ARE BLIND DUE TO BILATERAL CATARACTS
MOST OF THEM DO NOT GET OPERATED BECAUSE OF ECONOMIC LIMITATIONS.
CAUSES OF BLINDNESSIN LATIN AMERICA
CATARACT GLAUCOMA DIABETIC RETINOPATHY CORNEAL LEUKOMA
SOCIOECONOMIC STRUCTURE OF L.A
HIGH CLASS 5-10% MIDDLE CLASS 10-40% GHETTOS 10-40% RURAL POPULATION 20-80%
MAIN PROBLEM
NOBODY WANTS TO OPERATE ON THE POOR AND INDIGENT PEOPLE.
¿WHO PAYS?
THE PATIENT 35% RELATIVES 10% PRIVATE INSURANCE 5%
SOCIAL SECURITY 20% FEDERAL GOVERNMENT 30%
IN DOMINICAN REPUBLIC
OBSTACLES FORCATARACT SURGERY
MONEY FEAR DISTANCE CONFORMITY IGNORANCE BELIEFS
CATARACT SURGERY SHOULD BE :
AT A REASONABLE PRICE CONVENIENTLY ACCESSIBLE WITH APPROPRIATE
TECHNOLOGY
AVERAGE COST OF CATARACT SURGERY
AFRICA US$ 8-10 INDIA 12-10 HAITI 30-50 DOMINICAN .REP 100-300 COLOMBIA 300-500 CANADA 700-900
SIGHTFIRST MEGAPROJECTS
PROJECTS OF 200+ CATARACT OPERATIONS TOTALLY FINANCED
IDENTIFY CATARACTS AS THE ENEMY
IT IS A MODEL TO BE FOLLOWED AND IMITATED BY THE FEDERAL GOVERNMENT.
ROTARY`S MEGAPROJECTS
1,000 OR MORE OPERATIONS
DIRECTLY FINANCED
MANAGEMENT IMPORTANT AND ALSO SELF-EVALUATION
SEEING 2000 PROGRAMOF IEF
DIRECTED AT BLINDNESS PREVENTION IN INFANTS
SUPPORTS PROGRAMS FOR HYPOVITAMINOSIS, CATARACTS AND CONGENITAL GLAUCOMA
FINANCIALLY DEPENDENT ON AID MANAGEMENT IS VERY IMPORTANT
COLLABORATION WITHCHRISTOFFEL
BLINDENMISSION
YOU ARE IDENTIFIED BY THEM THEY HELP YOUR PROGRAM USUALLY
FOR 5% OF THE TOTAL COST VERY RESPECTFUL OF INSTITUTIONAL
GOALS AND RESOURCES THEY LOOK FOR LONG-TERM STATE
SUPPORT VERY PROFESSIONAL , STRICT, AND COST
CONSCIOUS
OPS PROGRAMS
GLOBAL SENSE OF PREVENTION IN A NATIONAL HEALTH PLAN.
THEY WORK DIRECTLY WITH THE HEALTH MINISTER
HEALTH MAINTENANCE ORGANIZATIONS ARE CREATED TO COMPETE AMONG THEMSELVES AS SUPPLIERS
MANAGEMENT STRATEGIES ARE SOUGHT TO IMPROVE PROGRAMS
IT CAN BE VERY POLITICAL ALTHOUGH THE ONG’S ARE SUPPORTED GENEROUSLY
CULTURE OF ORGANIZATIONS PYRAMIDAL VERTICAL SATELLITES MISSIONARY PRIVATE PRACTICE PUBLIC SERVICE COMBINATION OF PRIVATE
AND PUBLIC
PYRAMIDAL CULTURE
B O A R D O F D IR E C TO R S
S E C R E TA R Y
R E S ID E N T 1 R E S ID E N T 2
D IR E C TO R A C A D E M IC O IN V E S TIG A C IO N
C H IE F O F S TA F F
IN S TR U M E N TIS T C IR C U L A TIN G N .
C H IE F O F O .R .
H E A D N U R S E
M E D IC A L D IR E C TO R
A C C O U N TA N T
D A TA TE R M IN A L O P D A TA TE R M IN A L O P
P R O G R A M M E R
A U D ITO R
C O M P TR O L L E R
O U TP A TIE N T C L IN IC
S O C IA L W O R K E R P R E O P E V A L U A TIO N
P R O G R A M A C IO N
S U R G E R Y
E X E C U TIV E D IR E C TO R
P R E S ID E N T TE S O R E R O
PYRAMIDAL CULTURE THERE IS FUNCTIONAL HIERARCHY AND
JURISDICTION FOR EACH JOB DESCRIPTION
EACH EMPLOYEE IS RESPONSIBLE TO HIS SUBORDINATES AND BOSSES
THERE ARE MANY BOSSES, EACH WITH A NUMBER OF SUBORDINATES, BUT THE ONES THAT WORK THE MOST ARE AT THE BOTTOM OF THE PYRAMID
NOBODY IS INDISPENSABLE IN THIS SYSTEM
SATELLITE CULTURE
PRESIDENT
ISLAND OR SATELLITE CULTURE
EACH ISLAND HAS ITS OWN AUTONOMY BUT ALL THE ISLANDS ARE RESPONSIBLE TO ONE CHIEF
THE CHIEF HAS TO MOVE AROUND THE DIFFERENT ISLANDS TO SUPERVISE THE WORK DONE
REQUIRES MUCH COMMUNICATION, LOYALTY, AND CONFIDENCE
THERE IS LITTLE INTERACTION BETWEEN ISLANDS ESPECIALLY IF VERY REMOTE
VERTICAL CULTURE
B O A R D O F D IR E C TO R E S
TR E A S U R E R
C O R O N E L
TE N IE N TE
C A B O
R E C L U TA
R A S O
S A R G E N TO
M A Y O R
G E N E R A L
G E N E R A L S U P E R V IS O R S E C R E TA R
P R E S ID E N T
VERTICAL CULTURE IS TYPICAL OF MILITARY OPERATIONS BUT
ALSO IN RESIDENCY TRAINING PROGRAMS INFORMATION IS USUALLY QUITE ALTERED
BEFORE IT MAKES IT TO THE CHIEF THE CHAIN OF COMMAND IS EASILY
BROKEN IF SOMEONE IS MISSING EVERYONE IS AWARE OF WHAT THE CHIEF
WANTS OR THINKS THE CHIEF HAS TO WORK QUITE HARD BUT
DISCIPLINE AND ACCOUNTABILITY IS EASY
JOHNNY APPLESEED CULTURE
THE JOHNNY APPLESEED CULTURE
IS THE CONCEPT OF PLANTING MANY SEEDS HOPING THAT SOME WILL FIND THE RIGHT CLIMATE, SOIL, AND CONDITIONS TO GERMINATE
YOU DEPEND ON LUCK AND WISDOM CAN BE VERY WASTEFUL AND
EXPENSIVE BEFORE RESULTS ARE OBTAINED
THE MISSIONARY CULTURE
THE MISSIONARY LEAVES HIS FAMILY, HOME, COMMUNITY, AND
COUNTRY TO HELP FOREIGN COMMUNITIES HIS OR HER MINISTRY OF LOVE INCLUDES A
GREAT DEAL OF PERSONAL SACRIFICE, PARTICULARLY OF BASIC NEEDSSU MINISTERIO DE AMOR LE PERMITE SACRIFICAR SUS NECESIDADES, IN ORDER TO SERVE OTHERS
THEIR HOPE IS OFTEN IN THE AFTERLIFE AND MATERIAL PURSUITS ARE SECONDARY
MAY NOT UNDERSTAND WHY NATIVES FEEL DIFFERENTLY
PREVENTION REQUIRES
MOTIVATION PARTICIPATION GENEROSITY PERSEVERANCE DISCERNMENT LEADERSHIP PUBLIC
RELATIONS
TECHNICAL KNOWLEDGE
MARKETING GOOD
ADMINISTRATION HONESTY DEDICATION TOTAL
COMMITTMENT
THE BASIC NEEDS ARE
FOOD CLOTHING SHELTER PERSONAL SAFETY DREAMS AND HOPE
SECONDARY NEEDS ARE:
TRANSPORTATION EDUCATION OF CHILDRE ENTERTAINMENT FASHIONABLE CLOTHING VACATIONS AND LUXURY
ALTRUISTIC MOTIVATIONS USUALLY ARISE FROM:
THOSE WHOSE BASIC NEEDS HAVE BEEN FULFILLED
IT IS PROBABLY THE MAIN REASON WHY OUR ORGANIZATIONS ARE SO WEAK
THE NATIVE EMPLOYEE
WORKS FOR A LOW SALARY HARDLY MEETS HIS OR HER
BASIC NEEDS IS AFRAID OF THE ULTERIOR
MOTIVES OF THE MISSIONARY IS CONCERNED WITH THE
FUTURE UNLESS:
THE MISSION ACCOMPLISHED
MAY OFFER BETTER TRAINING, A BETTER PROFESSION, AND A BETTER FUTURE FOR HIS LIFE AND LOVED ONES
THEY NEED A GUARANTEE THAT THEIR COMMUNITY AND LIFE IS WORTH THE SACRIFICE
A FAMOUS OPHTHALMOLOGIST ONCE SAID, THAT PEOPLE SEEK YOU AS LONG AS THEY NEED YOU. It is a fatalist statement but quite true.
IT IS FOR THIS REASON THAT WISE PREDECESSORS TAUGHT US THE IMPORTANCE OF CONTINUING EDUACTION AND TEACHING IN ORDER TO RECYCLE THE TALENT
ORGANIZATIONAL ITEMS
MOTIVATION OF EMPLOYEES IS THE KEY TO SUCCESS
THE SCIENCE OF PSYCHOLOGY DESCRIBES THE NEEDS, ATTITUDE, MOTIVATION EQUATION IN MAN
NEED MOTIVATION ATTITUDE
MY WIFE’S NEEDS ARE
DAILY LOVE AND AFFECTION TIME ALONE BY OURSELVES EXPRESSED INTEREST IN WHAT
SHE DOES TO RECOGNIZE WHAT SHE HAS
DONE ACCORDINGLY AND JUSTLY LIBERTY TO CHOOSE AND MAKE
HER OWN DECISIONS
PRIVATE PRACTICE
PRIVATE PRACTICE
IS A NARCISSISTIC CULTURE EVERYTHING REVOLVES AROUND THE
CONFIDENCE , FAME, AND RESPECT FOR A SPECIFIC PHYSICIAN
REMEMBER NARCISSUS WAS BEAUTIFUL, HE ADMIRED HIMSELF, THOUGHT HE DESERVED EVERYTHING, AND WAS NEVER WRONG
NARCISSUS DROWNED IN A POOL TRYING TO REACH HIS OWN IMAGE
IT IS THE PREVAILING ATTITUDE AMONG OPTHALMOLOGISTS AND IT OFTEN COMPETES WITH INSTITUTIONAL CARE
I LEARNED IN COLLEGE THAT:
THE SMART GUYS GOT THE GOOD GRADES, WORKED VERY HARD, PLAYED VERY LITTLE, AND CAME UP WITH THE IDEAS THAT CHANGED THE WORLD
THE OTHERS PLAYED HARD, GOT POOR GRADES, AND MADE THE MONEY TO FINANCE THE IDEAS MADE UP BY THE SMART GUYS
FORMAL vs. INFORMAL CULTURE
THE INSTITUTION WILL TRY TO CREATE THE FORMAL STRUCTURE
THE EMPLOYEES CAN COME UP WITH A COMPLETELY DIFFERENT AND PARALLEL STRUCTURE THAT CAN COMPETE OR EVEN REPLACE THE FORMAL ONE
THIS OCCURS IN ALMOST ALL ORGANIZATIONS AND IT REQUIRES CONSTANT VIGILANCE
EXAMPLE OF WORKING EXTRA HOURS
FUNDAMENTALS OF SELF-EVALUATION
REQUIRES PHYSICAL PRESENCE TO VERIFY ATTITUDES, BEHAVIOURS, INVENTORY, SERVICE, VOLUME, APPOINTMENTS, AND SURGERY
REQUIRES A CONSTANT EFFORT TO IMPROVE THE SERVICE, HEALTHY GROWTH, AND A CULTURE DEPENDENT ON THE SELF-EVALUATIONS
GOOD COMMUNICATION AND VERIFICATION ARE ESSENTIAL
SELF-EVALUATION EXAMPLE
1. CATARACT SURGERY VOLUME GOES DOWN 2. THE COST MAY BE TOO EXPENSIVE, THE RESULTS
MAY NOT BE GOOD, PATIENTS MAY BE MISTREATED, THE WAIT IS TOO LONG. WHAT IS GOING ON?
3. SELF EVALUATION QUESTIONNAIRES CAN B E MADE FOR SUBJECTIVE AND OBJECTIVE DETERMINATIONS OF ALL FACTORS. PATIENTS ARE INTERVIEWED AFTER SURGERY, THE VISUAL RESULTS ARE CHECKED, FLOW ANALYSIS OF THE CLINIC IS DONE ETC.
4. CONCLUSIONS ARE MADE AND MEASURES TAKEN TO CORRECT THE PROBLEM
SELF-EVALUATION OF SURGERY
ALLEN FOSTER PUBLISHED HIS SYSTEM FOR EVALUATING THE RESULTS OF CATARACT
THE VISUAL CATEGORIES ARE DIVIDED INTO I, II, III, & IV. 20/20-20/40, 20/50-20/80, 20/100-20/200, 20/400-NPL
THE CATEGORIES ARE DONE PER PATIENT AND PER EYE
YOU MATCH THE PRE-OP SITUATION WITH THE POST OPERATIVE SITUATION
THE IDEAL IS TO TAKE MOST PEOPLE FROM III AND IV TO II OR I
ANALYZING COSTS OF CATARACT SURGERY
COST OF PRE AND POST OPERATIVE EVALUATION
COST OF DISPOSABLE MATERIALS COST OF OPERATING ROOM SURGICAL FEES COST OF IOL AND GLASSES INDIRECT COSTS(TRANSPORTATION,
TICKETS, FOOD, COMPANIONS, ETC.)
REAL COST
EVALUATIONS MATERIALS OPERATING
ROOM SURGICAL FEES LENS CORRECT. INDIRECT COST TOTAL
US$15 US$65 US$20 US$00 US$20 US$20 US$140
IN SANTO DOMINGO A CATARACT IS WORTH US$140 AT DR.
ELIAS SANTANA THE SAME SURGERY COSTS US$700 IN THE PRIVATE SECTOR
THE CONFLICT CREATED MUST BE FACED AND RESOLVED BY THE INSTITUTION
WE DO NOT OPERATE ON PRIVATE PATIENTS, WEALTHY PATIENTS, OR INSURED PATIENTS. WE ONLY OPERATE ON THE POOR
IF WE BREAK THIS RULE, WE WOULD LOOSE OUR VOLUNTEERS
COMPETITIVE ASPECTS POOR PATIENTS ARE QUITE WELL
INFORMED ABOUT TECHNOLOGICAL ADVANCES. THEY WATCH CNN, DISCOVERY, AND INTERNATIONAL TV
NOT INFREQUENTLY WE GET PATIENTS REQUESTING INTRAOCULAR LENS SURGERY, LASER SURGERY, OR PHACOEMULSIFICATION
YOU MUST BE SENSITIVE TO THEIR EXPECTATIONS OR YOU LOOSE THEIR CONFIDENCE IN THE SERVICE PROVIDED
VISION OF THE FUTURE
CENTERS OF ASSISTANCE TO THE POOR MUST BE MULTIPLIED AND INCREASED
FOR THIS TASK, NEW PROFESSIONALS ARE NEEDED
WE CANNOT WAIT FOR THIS TRAINING TO COME FROM OTHER COUNTRIES, WE MUST TAKE ON THE RESPONSIBILITY AND DO IT OURSELVES
THE IMPORTANCE OF SPECIALIZATION
THE SPECIALIZED PROFESSIONAL MUST DEDICATE HIS OR HER TIME TO THAT FOR WHICH HE/SHE WAS TRAINED
OTHER TASKS SUCH AS SCREENING, FOLLOW-UP, CHECK UPS, FLOW OF PATIENTS, MUST BE DELEGATED APPROPRIATELY
THESE DISCIPLINES INCLUDE:
VISUAL HEALTH PROMOTERS COMMUNITY BASED REHABILITATORS OPTICIANS OPHTHALMIC TECHNICIANS OPTOMETRISTS LOW VISION EXPERTS GENERAL OPHTHALMOLOGISTS OPHTHALMIC SURGEONS ADMINISTRATORS SOCIAL WORKERS
ADMINISTRATIVE TASKS
MATERIALS MANAGEMENT INFRASTRUCTURAL EQUIPMENT ADN
SPECIALIZED INSTRUMENTS HUMAN RESOURCES INCLUDING
TECHS, NURSES, MD’S, ETC. FINANCIAL RESPONSIBILITY
(ACCOUNTING, AUDITING, FUND RAISING PUBLICITY, STATEMENTS, ETC.)
CONCLUDING REMARKS SUCCESS OF THESE PROJECTS DEPENDS
ON LONG-TERM COMMITMENTS PERSEVERANCE OF STAFF APPROPRIATE MOTIVATION CONFIDENCE IN THE SERVICE PROVIDED ECONOMIC INDEPENDENCE CONTINUOUS ,CRITICAL SELF-
EVALUATION AND IMPROVEMENT SPIRITUAL GROWTH