THE ADJUSTMENT OF HEALTH CARE INFRASTRUCTURE TO …journal-healthmanagement.com/pliki/zasobydokumentu-pliki/71/PZ13... · Hanna Saryusz-Wolska STRESZCZENIE Infrastrukturà okreÊla

HEALTH CARE INFRASTRUCTURE

The infrastructure means all service facilitiesand institutions necessary for the properfunctioning of both the society and the productionsections of the economy1. There are manytypologies related to the characteristics ofthe infrastructure. The following is distinguishedin the economy:

a. economic infrastructure (facilities inthe domains of construction, transport,communication, energy, water procurement,environmental protection and defence)and

b. social infrastructure (institutions in thedomains of law, education, science, cultureand leisure, health care and socialwelfare).

In the modern society based on know-ledge, an integral element both of the economicand social infrastructures is the information

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The adjustment of health care infrastructure...

Journal of Health Policy, Insurance and Management – Polityka Zdrowotna

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Dostosowanie infrastruktury ochrony zdrowia do potrzeb zdrowotnych i oczekiwaƒ mieszkaƒców regionu – na przyk∏adzie województwa ∏ódzkiego

Hanna Saryusz-Wolska

STRESZCZENIE

Infrastrukturà okreÊla si´ wszelkie urzàdzenia i instytucje us∏ugowe niezb´dne do nale˝ytegofunkcjonowania spo∏eczeƒstwa i produkcyjnych dzia∏ów gospodarki. Wyró˝nia si´ infrastruktur´ekonomicznà i spo∏ecznà, do której zaliczamy instytucje w dziedzinie prawa, oÊwiaty, nauki,kultury i wypoczynku oraz ochrony zdrowia i opieki spo∏ecznej. Nowa polityka regionalna UniiEuropejskiej wskazuje na terytorialny wymiar procesów rozwojowych i koniecznoÊç tworzeniauk∏adów terytorialno-funkcjonalnych. G∏ównym celem poprawy infrastruktury ochrony zdrowiaw regionie jest podniesienie standardu Êwiadczonych us∏ug medycznych oraz zredukowanietrwa∏ej nieefektywnoÊci systemu ochrony zdrowia i trwa∏ego wykluczenia spo∏ecznego w dost´-pie do opieki zdrowotnej. Dostosowywanie infrastruktury do potrzeb zdrowotnych obywatelistanowi integralnà cz´Êç reformy systemu ochrony zdrowia.

W pracy przedstawiono dostosowywanie infrastruktury ochrony zdrowia jako z∏o˝ony procesplanowania. Planowanie infrastruktury opieki zdrowotnej stanowi równie˝ problem informacyjno--decyzyjny, a regionalne plany zdrowotne oparte na analizie dost´pnych danych powinny po-wstawaç w procesie negocjacji i wzajemnych uzgodnieƒ z g∏ównymi interesariuszami w regionie.Praca zawiera przeglàd metod i narzàdzi stosowanych w planowaniu opieki zdrowotnej w wy-branych krajach Unii Europejskiej.

S∏owa kluczowe: ochrona zdrowia, infrastruktura ochrony zdrowia, planowanie, dost´pnoÊç,efektywnoÊç

Key words: health care, health care infrastructure, planning, access, efficiency

1 J. Penc, Leksykon Biznesu Business Lexicon. Agencja Wydawnicza (Publisher„Placet”, edition I, Warsaw1997, page 163.

infrastructure2. The notion of health care infra-structure is very wide as in this area, there actnumerous public, private and social institutionsand the health care systems are consideredthe most complex as to structure and functions.The heterogeneity of organizations in the healthcare systems is shown by the division suggestedby Longest, who distinguishes3:

a. organizations which deliver health careservices („primary providers”, in Poland– medical units, service providers,currently health care activity units4),

b. organizations which produce resourcesto health care units („secondary providers”),

c. organizations which are regulators forthe activities of the both above-mentionedgroups,

d. organizations which represent both theabove-mentioned groups.

The infrastructure planning in the regionrelates to organizations which provide healthcare services, i.e. health care units. In 1999,the health care system reform introduced inPoland the market of medical services andthe competition between service providers.The infrastructure of the central and localadministration operates based on set outlegal provisions and it is assumed to have aunique nature, typical for a given state.

Jachimsen divides the infrastructureinto5:

a. material infrastructure (transport, tele-communications, power engineering,water procurement, buildings and facilitiesserving for education, culture, healthcare),

b. institutional infrastructure – naturallyshaped (culture) and established (public

authorities) standards and manners ofconduct which create frameworks foreconomic units acting and cooperating,

c. personal infrastructure which sets outabilities and talents of people necessaryin economic processes.

Activities within the EU cohesion policy,owing to the use of European funds are toimprove the quality of social infrastructure,local educative, sports and health careinfrastructure included, in particular in thefield of fighting against inequality betweenrural and municipal areas6. The main purposeof the health care infrastructure improvementis to raise the standards of health care servicesprovided by:

• securing the access to high quality healthcare, in particular, in rural and in smalltowns areas,

• limiting territorial disproportions in healthcare infrastructure,

• improving the technical conditions ofbuildings through their renovation andupgrading,

• improving the quality of furnishing of out-patient units and hospitals with specializedmedical equipment.

The new regional policy of the EuropeanUnion indicates the territorial dimension ofdevelopment processes and the necessity tocreate territorial and functional systemswhose main objective should be to reduce: a.the permanent inefficiency and b. theconstant social exclusion (Fabrizio Barca’sreport)7. That is why planning the healthcare infrastructure in the region shall implementboth the basic purposes. The adjustment ofthe health care infrastructure in the region

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2 In ¸ódê Province an integrated project of “Regionalnego System Informacji Medycznej RegionalSystem of Medical Information” – RSIM-Infrastructure and RSIM-Services was implemented, comparersim.lodzkie.pl

3 Compare B.B.Longest, jr. BB: Management Principles for the Health Professional, 4th edn. Appleton&Lange,Norwalk, CT 1990.

4 The 15th April 2011 Act on Health Care Activities (Journal of Laws 11.112.654).5 Por. J. Jachimsen: Infrastructure for the built environment. Elsevier’s Science and Technology Rights

Department in Oxford, UK Iwan P.K. 2010.6 www.funduszeeuropejskie.gov.pl [access on 1.10.2013].7 Barca F., Program dla zreformowanej polityki spójnoÊci. PodejÊcie ukierunkowane terytorialnie w osiàganiu

celów i oczekiwaƒ Unii Europejskiej, Programme for reformed cohesion policy approach directed territoriallyto achieve objectives and expectations of the European Union April 2009, http://www.mrr.gov.pl/fundusze/Fundusze_Europejskie_2014_2020/Negocjacje_2014_2020/Raporty/Documents/raport_barca_pl.pdf,[access on 1.10.2013].

must take into account: a. the assessment ofthe initial condition, b. the assessment of futurehealth care needs, c. the assessment of futurepotential to finance health care services(costs of infrastructure maintenance) and d. acomplex ownership structure of health careunits in the region (founding authorities are,among others, local government of various levels,public medical universities, private entities).

The adjustment of the infrastructure tothe medical needs of the residents makes upan integral part of the system reform whichis composed of complex co-dependent changesintended and unintended, both cohesive andin conflict against each other, implementedat various decision and performance levels,running with differentiated effect8.

I. Planning as a base to adjust health careinfrastructure to the health care needs in the region

Planning in the health care is the resultof undertaken public interventions (the stateas the regulatory unit) and market mechanisms9.In the sector of medical services, we canmention: a. full planning, b. adaptationplanning, c. planned market, d. regulatedmarket and free market (which in thedeveloped countries does not exist in practicebecause of numerous regulations)10.

The limitations of market mechanisms inthe health care11, the imperfect competitionand failure to fulfill the market efficiencycriteria result from the functioning principlesof a modern state which by numerous legal

regulations sets out its health care system,having it that we can speak both of an“inefficient market” and “inefficient state”12.

In accordance with the theory of managementsciences, we can plan only what can be underour influence. Future events, outside the controlof the planner, may be anticipated or forecast.Planning of health care resources whichrefers to future demographic and epidemiologicphenomena fulfills the criteria of forecasting.There are many methods applied to forecastin health care13.

The basic features of each plan are:advisability (definition of resources leadingto an objective) and feasibility (achievementof the objective is probable with the availableresources and in set out conditions). Theperiod of economic slowing down and theuncertainty related to the economic situationof the European Union Member States, Polandincluded, has it that all long-term plans (forinstance health care plans for the period from2014 to 2020) are charged with a significantrisk. The assumptions of the new EU policyindicate a necessity to ensure the flexibilityand adaptability of all plans. In the conditionsof a risk difficult to be assessed, the meaningof plans grows as they allow to prepare better,to accept and adapt to changes in the socialand economic sphere.

The health care objectives at a domesticand regional level may be considered in twoaspects:

• as a kind of „international standard”,characterizing modern health care systems14

and

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8 Compare A.A. Cribb [cited after:] W∏odarczyk C.W.: Reformy zdrowotne. Uniwersalny k∏opot. Healthreforms. Universal problem. Publishing House of Jagiellonian University, Cracow 2003.

9 Bednarczyk M., Organizacje publiczne. Zarzàdzanie konkurencyjnoÊcià, Public organizations.Management in competitveness PWN Naukowe Publishing House, Warszawa-Kraków Warsaw-Cracow2011, p. 11-17.

10 Saltman R.B., von Otter C., Planned Market and Public Competition. Open University Press, Bristol, PA 1992.11 Mechanic indicated numerous reasons to limit the market mechanisms in the health sector, assymetry

of information included, together with difficulties to access to information, uncertaintity as to the resuktsof taken up activities, standards of medical proceedings (finishing of activities), relation of representation,risk difficult to be insured, irregular and unforeseeable demand and external effects (Mechanic, MedicalSociology, London 1978).

12 N. Barr: The Welfare State As Piggy Bank: Information, Risk, Uncertainly, and the Role of the State.Oxford University Press, Oxford 2001, page 81.

13 Astolfi R., Lorenzoni L., Oderkirk J., A Comparative Analysis Health Forecasting Methods, OECDHealth Working Paper, No. 59/2012, OECD Publishing.

14 W∏odarczyk C., Poêdzioch S., Systemy zdrowotne. Health care systems. Publishing House of JagiellonianUniversity, Cracow 2001, p.13.

• as a result of local choices which are alwaysa result of health care needs on the onehand and the financial resources on theother hand.

The objectives and tasks of the healthcare system shall be implemented both at acountry and local levels. A particular roleunderlined in the new EU regional policy isascribed to the region as a functional andterritorial unit in which most health careneeds should be implemented, starting fromthe primary health care through specializedto highly specialized and long-term healthcare.

In the current international papers, thefollowing are the most frequently listed ashealth care objectives15:

• improvement in the efficiency and costcontrol,

• justice and reduction in inequalities inthe access to the health care.

a. Health care needs as a base to planhealth care infrastructure The health care infrastructure planning

is based most frequently on setting outfuture demands and the adjustment of thetype and level of health care services offer.There are many methods of resourcesplanning based on explicit and implicithealth care needs16. There is a common ideathat the aging society17 consumes many moremedical services and the development oftechnologies and new treatment methodsadditionally multiplies the demand for theseservices. We can also foresee new productsand types of medical care which may changeand/or reduce the consumption of healthcare services18.

Health needs, in particular thoseexplicit, must be taken under consideration.However, the existing possibilities for healthcare services financing shall be referred andthe existing infrastructure modified throughthe control of costs plus quality and thecoordination of health care. The failure tohave either quality control or coordinationbetween service providers is the mostimportant problem of the current healthcare system19. After the period in which a lotof new health care units came into being andcontracts with the National Health Fundwere dispersed the stage of coordinationand concentration should start. It is only animprovement in the efficiency that maystraighten the results of the health caresystem.

Multiyear projections related to growinghealth care expenses20 force us to modifyand to make more realistic the approach toplanning health care resources and to basethem not only on an analysis of needs butmainly on possibilities to finance health careservices. For a few years, new directions ofchanges in the systems of health care havebeen suggested. More and more frequentlyinstead of the term „management in health-care” (management which includes planningin health care) the notion „governance in health-care” is used. The term of „governance”(„co-managing”) underlines the participationof many public, private and social partnersin taking difficult decisions and the necessityto co-decide on the allocation of more and morelimited resources.

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15 Joumard I., André C., Nicq C., Health Care Systems Efficiency and Institutions, OECD EconomicsDepartment Working Paper, No. 769/2010, OECD Publ.

16 Report, Resources allocation, weighted capitation formula, 6th edition, 12 Dec 2008 (report accessibleat www.dh.gov.uk/allocation).

17 Oxley H., Policies for Healthy Aging, An Overview, OECD Health Working Paper, No. 42/2010,OECD Publ.

18 An example may be a development of telemedicine, mobile facilities registering the functioning of organismor subcutaneal diagnostic implants.

19 The speech of Ms. Agnieszka Pachciarz, President of the National Health Fund NFZ during the 8th Forumof Health Market, Warsaw 24th-25th October 2012.

20 Compare Scherer P., Deveax M., The Challenge of Financing Health Care in the Current Crisis, An AnalysisBased on the OECD Data”, OECD Health Working Paper, No. 49/2010, OECD Publishing.

b. Improvement in the access as an objective of infrastructureplanning in the health care

The improvement in the access to medicalservices is given as one of the basic reasonsfor health care planning. The access is setout as an indicator of the quantity, type andplace of providing health care services inrelation to the health needs.

The health care is accessible to patientsif they may be provided with good qualityhealth care services in convenient time andplace. The access may be analyzed as: (1)territorial access (territorial distribution ofresources), (2) organizational access (mannerof adjustment services provided to thepatients’ needs, hours of out-patient unitsoperation, possibilities to check in on thephone or by the Internet), (3) cost access(bearing set out costs of services, paymentfor medicines).

In European documents (e.g. HealthCare in Transition21), the following notionsare distinguished:

• access – a formal right to health care,arising from the legal system22,

• availability – the real potential to usemedical services.

We could analyse many data, characterisingvarious types of access and dynamics of theirchanges (improvement or worsening): thewaiting time for set out medical procedures,the number of carried out diagnostic ortreatment procedures referred to thepopulation number, refusals to admit tohospital, the time of transfer to hospital orout-patient units, giving up the purchase ofmedicines. A crucial indicator of access maybe patients’ migrations for treatment toanother region than that in which theyreside23. Coming into force on 25th October2013 of a UE Directive on Patients’ RightsIn Cross-border Health Care24 may reveallimitations in the access to many treatmentprocedures in various regions of the State.

c. Improvement in the efficiency as an objective for planning the health care infrastructure

The health effects depend upon manyfactors25, the appropriate planning and the useof health care resources included26. Thereare many simple and complex indicators,characterizing health care27, whose main taskis to create a convenient pool of health careservices in the proper number and quality.With the growing health needs and limitedfinancial resources, the efficiency/performance

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21 Compare Report (collective work), Poland, Health system review. Health Systems in Transitions, 2011,13(8), 1-193; Boyle S., United Kingdom (England), Health system review. Health Systems in Transition,2011; 13(1), page 1-486; Joumard I., André C., Nicq C., Health Care Systems Efficiency and Institutions,OECD Economics Department Working Paper, No. 769, OECD Publ., Paris 2010.

22 Pursuant to the law in force (the Act on Health Care Services Financed from Public Resources) in Poland there is universal access to health care services.

23 ¸ódz Branch of National Health Fund NFZ in 2012 bore costs of patients’ treatment in other regionsat over 1 mln PLN.

24 The 2011/24/EU Directive of the European Parliament and Council of 9th March 2011 on Patients’Rights In Cross-border Health Care, Official Journal of the European Union L 88/45.

25 Burns L.B., Bradley E.H., Weiner B.J., Shortell and Kaluzny’s Healthcare Management, OrganizationDesign and Behavior, Delmar, Clifton Park, NY 2006, page 13.

26 Joumard I., André C., Nicq C., Chatal O., Health Status Determinants, Lifestyle, Environment, HealthCare Resources and Efficiency, OECD Economics Department Working Paper, No. 627, OECD Publ.,Paris 2008, page 8.

27 Joumard I., André C., Nicq C., Health Care Systems Efficiency and Institutions, OECD EconomicsDepartment Working Paper, No. 769/2010, OECD Publ., page 28-29 I 48; Drösler S., Romano P., Wei L.,Health Care Quality Indicators Project, Patient Safety Indicators Report 2009”, OECD Health WorkingPaper, No. 47/2009, OECD Publishing, Health at a Glance, Europe 2011.

of all undertaken actions becomes the basicproblem which is a function of effectivenessunderstood as the degree of implementationof the objective and outlays28.

The OECD report „Towards High-Performing Health Systems” published in2004 compared the efficiency of health carein various states, analyzing, among others,the long-life expectancy, the type anddynamics of expenses on health care, theaccess to health care measured by thewaiting time for several medical procedures,the indicators of health care quality,compliance to treatment standards (EBM),the results of treatment (for instance oneyear survivability of patients after a stroke),the availability of medicines and manyothers. The OECD papers29 and The HealthCare Systems in Transition (HiT)30 give mostinformation with reference to the efficiencyof the health care systems.

The AHRQ report „Identifying,Categorizing, and Evaluating Health CareEfficiency Measures” gives a definition ofefficiency as “a connection between theoutput, specific for the health care systemand the inputs used to create this product”.To assess the efficiency, a typology wassuggested, taking into account the prospects(who assesses the efficiency, who is assessedand what is the purpose of the assessment),the output (what kind of product is assessed),the outlays (which inputs are engaged to createthe output)31.

From a practical point of view, the assessmentof efficiency seems to be significant, takinginto account the health care organizationallevels and their mutual relations:

1. the efficiency of the whole health care(systematic efficiency),

2. the efficiency of the region as a functionalpart of the health care system,

3. the efficiency of various organizations, actingin the health care system (organizationaleffectiveness),

4. the efficiency of medical and paramedicalactivities related to patients’ treatment(process efficiency).

The systematic efficiency relates to reci-procal co-dependencies requiring correspondingplanning activities and interorganizationalcoordination in the filed of planning,organizing and control of tasks in the field ofhealth care32. Various methods and tools forhealth care planning in the region shalleliminate less efficient units and create theoptimal structure of health care units as tothe quantity, type and territorial distribution.The management over the organizationalbarriers, and the management of servicesnetworks or the care coordination33 give thesynergy effect and improve the efficiency ofhealth care, in particular, in case of chronicdiseases and in the care for patients over 80years of age (80+)34.

Organizational efficiency(organization, healthcare unit-hospital or out-patient surgery).

Lighter distinguishes a few categories ofmeasurements which show various aspectsof organizational activities and processesrunning therein, in which are included:a. financial, b. utilization – related to the properuse (of equipment, machines, medicines),c. compliance (for instance: number ofprocedures falling to individual medicalgroups, number of hospital admittances anddays of patients stay at a ward), d. diseasespecific – related to the treatment of a given

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28 Barr N., The Welfare State As Piggy Bank, Information, Risk, Uncertainly, and the Role of the State.Oxford University Press, Oxford 2001, page 81.

29 http.//www.oecd.org/health/healthpoliciesanddata/>30 www.euro.who.int/en/what-we-do/data-and-evidence/databases/>31 Report AHRQ (Agency for Healthcare Research and Quality): “Identifying, Categorizing, and

Evaluating Health Care Efficiency Measures”, AHRQ Publ. No.08-0030, Rockville, MD 2008.32 Shortell S.M., Kaluzny A.D., Podstawy zarzàdzania opiekà zdrowotnà, Health care management basis

„Vesalius” University Medical Publishing House, Cracow 2001, p. 242-24333 Hofmarcher M.M., Oxley H., Rusticelli E., Improved Health System Performance through better Care

Coordination, OECD Health Working Paper, No. 30/2007, OECD Publishing, page 49.34 Oxley H., Policies for Healthy Aging, An Overview, OECD Health Working Paper, No. 42, OECD Publ., 2009.

disease, e. satisfaction with care. Theefficiency may be measured at a level of: thewhole organization, its organizational units(wards, working places) and individualprocesses. The basic processes are thediagnostics and the treatment ones whichrelate to norms and standards of care quality,corresponding to the guidelines of medicalproceedings (EBM). The compliance to healthcare standards (guidelines) makes up one ofthe basic criteria for the assessment of thehealth care organization efficiency.

Among the concepts of organizationalefficiency assessment in the health caresystem or else the efficiency at the level of agiven hospital, the balanced scorecard(BSC) is applied and the six sigma businessscorecard.

The improvement in the organizationalefficiency of health care units (zoz) requiresthe application of several methods andtechniques taken from the management ofbusiness, for instance35:

1. restructuring (mergers and divisions,founding holdings, diversification),

2. TQM (total quality management) andCQI (continuous quality improvement),

3. horizontal and vertical integration (securethe continued care, reduction in businesscosts, co-operation and common use ofresources, exchange the information),

4. strategic alliances and founding serviceproviders’ networks,

5. work restructuring,6. customer focus.

II. Health care infrastructure planning as a complex process of information and decisions

Planning is a process of creation of a plan,consisting in an aware establishing of businesspriorities and taking up decisions based onobjectives, facts and well thought overassessments36. Decisions in the health caresystem shall be taken in multi-stage, multi-subject reconciliations, the application ofsuch procedures: consultation, co-operationand co-deciding37 included. The newregional policy, encompassing the healthpolicy, emphasizes the role of: a dialogueand deliberation procedure and three-sectorhybrid solutions (public-private-socialpartnership). Decisions in the health caresystem belong to the most difficult socialchoices as38:

a) the preservation of health and life makesup the greatest value and the needs inthe field are often fundamental, decidingon the individuals’ sense of security(decisions refer to an important, difficultand sensitive sphere of public life),

b) the procurement system of health care,functioning for several years has beengoing through a serious organizationaland financial crisis, requiring radicalchanges (inevitable and radical decisionsto which quite often we are not sociallyprepared),

c) in the health care system, there often occurinterest conflicts of various stakeholdersand units (local government of variouslevels, the National Health Fund – NFZ,service providers, social groups andemployee groups) and therefore, thedecisions require negotiations and theconsensus,

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35 Burns L.B., Bradley E.H., Weiner B.J., Shortell and Kaluzny’s Healthcare Managament, OrganizationDesign and Behavior, Delmar, Clifton Park, NY 2006, p. 12.

36 Barrow C., 1992 [cited after:] Koêmiƒski A.K., Piotrowski W. (edited), Zarzàdzanie. Teoria i praktyka,Managemen. Theories and practice. Edition V. PWN Naukowe Publishing House, Warsaw 2001, p. 179.

37 The new regional Policy of the European Union indicates the territorial nature of developmentprocesses and the necessity to create territorial-functional systems whose main purpose shall be a. to reducea permanent inefficiency and b. the permanent social exclusion (Fabrizio Barca’s report).

38 Saryusz-Wolska H., Pozyskiwanie, wykorzystanie i ochrona informacji niezb´dnych do podejmowaniadecyzji w ochronie zdrowia. Acquisition, use and protection of the information necessary to take up decisionsin the health care system [in:] Technologies of knowledge in public management ’07. Published by AE,Katowice, 2008, p. 237-251.

d) the decisions are taken on variouslevels by various units and groups (theyrequire a coordination and cooperation),

e) the decisions are charged with a significantdegree of risk and uncertainty.

In the health care management, manysources of information are used, both at thecentral and regional level and in the healthcare units (service providers)39. A greatnumber of data are at the disposition of payers,in our condition – the National Health Fund(NFZ). The data, relating to the functioningof the health care sector are collected andanalysed at an international level, in particular,in the of the Member States EuropeanUnion40 and those belonging to the OECD41,which gives a possibility to make internationaland interregional comparisons.

The information exchange in the healthcare system is dealt with by the Regulationsof the Minister of Health, which areexecutory acts to the 27th August 2004 Act onHealth Care Services Financed from PublicResources (unified text, Journal of Laws08.164.1027), which refer to: medical records42,information gathered by service providers43

and the NFZ Information Technology system44.Among the data, describing the functioning

of the health care system in Poland, thefollowing, in particular, may be mentioned:

a. public statistics, b. information resourcesof the National Health Fund (NFZ) andc. information resources of regional healthcare centres.

At the regional level (provinces) the RegionalPublic Health Care Centre is active and itmakes available its information to the unitsengaged in the creation of the health policy,planning included, at a local and regionallevel45.

The introduction of the electronic healthrecord (EHR), the information technologylaunched into health care units or into the systemas an entirety is a essential tool, allowing totake up decisions related to individual patients’therapy, health care organization activitiesand pro-health care policy46.

III. Methods and tools for health careinfrastructure planning – examples

Most methods applied in health care infra-structure planning (of tangible and intangibleresources) are based on an analysis of healthneeds. The WHO defines the definition ofhealth and health needs, distinguishing theneeds explicit (corresponding to the demand

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39 Jas∏owski J., Informacja jako narz´dzie wspierajàce racjonalne zarzàdzania ochrona zdrowia w skaliregionalnej i ogólnokrajowe, The information as a tool to support the rational management in the healthcare system in the regional and all-Poland scale. [in] Fràckiewicz-Wronka A., Jas∏owski J., Owcorz-CydzikB., Sobusik D., Self-government health policy. Scientific Works of the Economic Academy in Katowice,Katowice 2004, p. 164-192.

40 http.//epp.eurostat.ec.europa.eu/statistics_explained/index>41 http.//www.oecd.org/health/healthpoliciesanddata/>42 The Regulations by the Minister of Health of 21st December 2006 r. On Type and Scope of Medical

Record in Health Care Units and Manner of Their Processing (Journal of Laws 06.247.1819)43 The Regulations by the Minister of Health of 29th July 2005 On the Scope of Necessary Information

Gathered by the Service providers, a Detailed Manner of Recording This Information and Its Transfer tothe Units Obliged to Finance Service from Public Resources (Journal of Laws 05.176.1467).

44 The Regulations by the Minister of Health of 27th July 2005 On the Scope of Necessary InformationGathered in the Information System of the National Health Fund and the Scope and Manner of itsTransfer to the Minister Proper for Health and Governors, as well Local Government Parliaments(Journal of Laws 05.152.1271)

45 Compare www.wczp-lodz.pl, publications „Dzia∏alnoÊç zak∏adów lecznictwa zamkni´tego województwa∏ódzkiego 2012 „The activities of closed health care units of ¸ódê Province 2012”, „Informacje o staniezad∏u˝enia samodzielnych publicznych zak∏adów opieki zdrowotnej województwa ∏ódzkiego na dzieƒ 30czerwca 2013 r.” „The information on the indebtedness of the independent public health care units in¸ódê Province as on 30th June 2013” and other.

46 E.G. Poon, A. Wright, S.R. Simon, C.A. Jenter, R. Kaushal, L.A. Volk, P.D. Cleary, J.A.Singer, A.Z.Tumolo, D.W. Bates: Relationship between use of electronic health record features and health carequality: Results of a statewide survey. “Medical Care”, 2010, Mar;48(3)

for medical services) and implicit. The healthcare infrastructure planning may refer to:

- an assessment of health needs based onforward looking analysis of socio-demographic and epidemiologic data or

- an assessment of health care offer (under-stood as the delivery of quantitativelyand qualitatively satisfactory medicalservices) based on future financial andorganizational potential (improvementin the efficiency).

a. Examples for planning methods based onsocio-demographic indicators

The British RAWP method (ResourcesAllocation Working Party) – in Great Britain,the scientific methods of resources planningin health care (NHS – National HealthService) were launched in 197647. Theresources were planned based on socio-demographic and epidemiological data, forinstance: number of residents, distributionaccording to gender, age, place of residence,number of people over 75 years of age livingalone, indicators of education level, income,unemployment, rates of disease incidents,rate of death according to reasons of death,birth rate. An analysis of data is used forcreate numerous complex algorithms whichdetermine the distribution of financial resourcesinto individual regions. Additional, privatehealth insurance has it that the current offerof health services is better adjusted to thehealth needs determined by the public andprivate financial resources in disposition.

The Canadian method – the health carein the Canadian province of Ontario isconsidered one of the best in the world48.Planning resources takes place based on thesocio-demographic data, for instance: populationsize, age and gender structure, life expectancy,level of employment, income, number ofaged people living alone. Human resourcesin the region have been planned for manyyears and the data have a crucial impact onthe quality of health care49. In the Ministryof Health and Long Term Care of the Provinceof Ontario, a precise description of abilities,scope of responsibility, places of employment,required basic and additional qualificationsand conditions to be fulfilled to get employedon a given position have been drawn up for24 regulated medical professions50.

The French method – in 1992 in France,regional plans for sanitary organizationwere introduced (SROS – Schémat Regionald’Organization Sanitaire)51. Currently, “thefourth generation” of plans is under way.The method is based on a classical allocationof resources based on an analysis of socio-economic and epidemiological data whichhave an impact on the consumption ofhealth care services. Furthermore, the numberof people suffering from chronic diseases(ALD – affection longue dureé) is set out asthey must be included in a minimumguarantee package of medical servicescovered in 100% by the public insurance. In2004 and 2009, there were subsequent legalregulations related to the functioning ofhospitals, the rights of patients and thehealth care organization in the region. Oneof the most important changes was thecreation in 2009 of new decision entities –

31



47 Knox E.G., Principles of allocation of health resources, Journal of Epidemiology and CommunityHealth, 1978, 32, p. 3-9.

48 Compare http://www.health.gov.on.ca/en/?49 The report, Mod¯le de simulation fondé sur les besoins en personel medical dans la population en Ontario.

Model of the simulation based on the needs of medical personnel in the population of Ontario, the Ministryof Health and Long-Term Care, Ontario, Canada, October 2010.

50 Report, Health Human Resources Toolkit. Health System Intelligence Project, Ontario, April 2007.51 Compare http://ecosante.fr/FRANFRA/>

Regional Health Agencies (ARS – AgencesRégionales de Santé)52, which co-ordinate theregional planning of health care offer.

b. Methods of planning based on otherindicators than socio-demographic data

The method of hospital care planningapplied in France is based on collecting theso-called „key information” related to theactivities of hospitals. The research tools arequestionnaires directed to generalpractitioners (GPs) and private doctors(médecins libéraux), which make up astrong group of professionals. The offer ofhospital services in various medicalspecializations is assessed (for instance thewaiting time for treatment, the distance ofthe hospital from the residence of patients,relations between hospital professionals andthe referring doctor, the hospital technicalequipment and the application of “goodmedical practice”) as well as the dynamics ofchanges (improvement, worsening, nochanges). In France, future needs of hospitaltreatments are forecasted in the regions53.

In France, between 2001 and 2006, a obligatoryassessment of all hospitals was conducted,according to a centrally set out standard54.The hospital founding authorities, stillbefore starting the procedure, adopteddecisions to liquidate many hospitals (about12%). Another assessment conducted between2007 and 2012 was based on an analysis ofthe hospitals’ activities (type, number and

quality of health care services). Hospitalswhose activities are particularly importantfor the region and which implement theprogrammes of quality improvement shallbe granted additional, financial resourcesfor their development.

Method of health care planning forpatients with chronic diseases – in France, achronic disorder of kidneys is included in todiseases requiring the patient being coveredby a package of basic guaranteed servicesrefunded in 100% by public insurance (ALD– affection longue dureé). The questionnairehad a national range and the patientsanswered to questions related to, amongothers: the place of treatment, the numberof procedures conducted in a given year, theequipment, the medical personnel, the medicalinformation received, the cooperation betweenthe centre of specialized treatment and otherdoctors and hospitals. The research allowedto assess the health services in this group ofpatients at a national and regional level.

Method of health care planning basedon a register of chronic diseases – in Denmark,registers are conducted to allow to administerhealth care at a national and regional level.Apart from the register of residents andthose insured, there is a national register ofpatients which contains the data related topatients’ admittance and treatments in allpublic and private health care units (bygeneral practitioners also). Registers have acohesive information network which allowsto analyze several complex health risks,conditions and factors that make a patients’benefit of the health care system55.

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52 The Regional Health Agencies were founded in 2009 to co-ordinate the health care in the regions andin particular to improve the efficiency and transparency of the health care organization and financing.They are composed of many organizations which have existed for long time, for instance regional anddepartmental directions of departments of health and social care, the regional hospital agency, theregional groups of public health, the regional direction of health care, the regional union of healthinsurance fund (URCAM) and union of other insurers (CRAM, MSA, RSI). Information available athttp,//www.ars.sante.fr/Presentation-generale.89790.199 and at the websites of the regions, for instance,www.ars.iledefrance.sante.fr; www.ars.rhonealpes.sante.fr

53 Based on the current number of hospital beds in individual types, the hospitalization in the indicesaccording to the age, gender and main reason of treatment, the indicators of falling ill and the death rateand the demographic projection up to 2030 (method OMPHALE, INSEE) the future needs of hospitalcare are estimated.

54 Chevreul K., Durand-Zalewski I., Bahrami S., Hernández-Quevedo C, Mlodovsky P.: France: Healthsystem review. Health Systems in Transistion, 2010; 12(6), p.1-291.

55 The information related to individual reports: www.dst.dk, www.im.dk, www.sst.dk, www.regioner.dk.

Method of health care planning basedon specialists’ recommendations – specialists’recommendations constitute an importantsupport to epidemiological data. Putting intopractice the principles of evidence based medicine(EBM) allows to obtain better effectiveness,and quite frequently the efficiency oftreatment. An economic analysis makes upcurrently a permanent element of medicaltechnologies assessment and the clinicalguidelines.

CONCLUSION

The regional health plans, infrastructureplanning included, are adopted in the processof negotiations and reciprocal reconciliationswith the main stakeholders of the health caresystem in the region, who are: local government,service providers, public payer (National HealthFund, NFZ), regional specialists in variousfields of medicine, representatives of medicalprofessionals’ groups, non-governmentalorganizations and many others.

Each analysis of the data, characterizingthe health care infrastructure makes up onlya support to take up decisions which requirea perfect knowledge of local problems asthey frequently infringe the existing systemof power, influence and individual and groupinterest. Planning of the regional health careshall be based on the simplest methods whichshall allow to set out in relatively short-termwhich units, providing health care servicesshall be restructurized, for which reasons,and which should be liquidated.

The general tendency in hospital careplanning is: a concentration of services (closingof small hospitals or transforming them intolong-term care centres), quality and costscontrol of medical services. In this way, lessefficient units are eliminated from the marketand a new regional network of hospitals iscreated.

The analysis of the existing infrastructureand planning the future, modified networkshall connect the structural aspects with thefunctions. That is why the structural analysis,defining for instance: the total number ofhospitals, the number and size of public hospitals,the number and size of non-public hospitals,territorial distribution of hospitals, total numberof beds – region, number of beds, accordingto the type of activities, number of total bedsper 1000 residents and according to types ofactivities shall be connected with the analysisof a given service provider’s activity, defining,for instance, the total number of hospitaladmittances, the total number of medicalprocedures and according to ICD-10, thenumber of planned procedures, the numberof emergency procedures. An essential elementof service providers’ assessment shall be ananalysis of costs and of positive and negativequality indicators. Special analyses with theapplication of more advanced tools may assessthe course of interorganizational processes(care coordination in the region). Such typeof analysis as a pilot programme is implementedin various states56. In ̧ ódê region, the projectentitled “The Regional System of MedicalInformation of ̧ ódê Province” was implemented(eZdrowie).

Without a functional assessment of theindividual service providers, thus of the typeand quantity of services, their quality andcosts, (without benchmarking or parametricassessment of units) all activities related tohealth care infrastructure planning have onlya reactive nature and refer practically to twoaspects: a. negative and worsening financialresults of the unit (growing indebtedness) andb. impossibility to fulfill the basic requirementsrelated to hospital conditions and facilitiesin which health care activities are run57.

33



56 http://www.richardproject.eu 57 The Regulations by the Minister of Health of 26th June 2012 on Detailed Requirements to which shall

Correspond the Premises and Facilities of the Health Care Unit pursuant to Art. 22 subparagraph 3 of the15th April 2011 Act on Health Care Activities (Journal of Laws Dz. U. 112, item. 654, as amended).

The infrastructure planning shall run inaccordance with the axis: an analysis of serviceoffer – its quality – its costs – its efficiency.The health care efficiency in the region maybe improved applying mechanisms of co-ordination, cooperation and recomposition(change of system between individual serviceproviders). To implement one of the mainpurposes of the new regional policy of theEuropean Union and to reduce permanentlack of efficiency, the latter shall be measured(its quality and costs) at the level of organizationand processes and consequent decisions shallbe undertaken to limit the occurrence of unitsof low efficiency (poor quality and high costs).

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37



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38


2013 • XIII/III

63Olejaz M

., Juul Nielsen A

., Rudkj?bing A

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.: Denm

ark: Health system

review. H

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2012; 14(2), p.1-192.64C

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review. H

ealth Systems in Transistion, 2010; 12(6),

p.1-291.65T

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health and social welfare, organizing and financing. T

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health care, the regional union of health insurance funds (UR

CA

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generale.89790.19966Toniolo F., M

antoan D., M

raress A.: V

eneto Region, Italy: H

ealth system review

. Health System

s in Transition, 2012; 14(1), p.1-138.