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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