hsm Flashcards
forces
The healthcare system knows a couple of structural elements that shape and impact the way it works
fores 1-5
Infrastructure
health care providers
governance
knowledge
value, politics & law
infrastructure
division of tasks and responsibilities, levels of netwerk
healthcare providers
healthcare delivery institutions, medical professionals organisations
Governance
taking care
It is about the way the goverment controls and holds institutions that carry out public tasks accountable for what they do
in healthcare this is how defined core values
advisory bodies
boards consisting of experts who advise the government on policy
knowledge institutions
organisations that generate knowledge
- universities
-
value, politics and law
it starts with value, from a personal or societal perspective
These translate into political debates and law
Vulnerability
is a process of increasing physical, mental and social functional shortcomings, that together significantly increase the chance on disease, disability or death
overregulatie als gevolg van poging de zorg
- meer ondercontrollen te krijgen
- marktsysteem: elke actie moet geregistreerd, beprijsd
resilience
the ability to get back into the same shape or condition after a disturbing event has taken place
redundancy
reserve capacity: having more resources than needed in the expected situation, having something to fall back on
sustainable
a state or circumstance that enable prolonged reliable functioning of a particular system or person
reliable
a system or person that functions as expected and intended. Example: high-reliability organization (HRO)
you have to start with the user experience and work back to technology
- identify the user and understand what the user needs
- recognize what the user needs is not always what he/she asked for
- therefor you need to understand the problem
user being either the patient or the health care
traditional healthcare model
revolves around the concept of DISEASE
and a rather ‘mechanical’ way of thinking and reasoning
Reductionism
its like asking blind man what at elephant feels like: they are right (in their own area), but do not see the whole picture
What’s missing in the traditional medical approach?
It is not necessarily bad or disfunctional, but it has its limitations
- focus on well-being, instead of absence of disease
- context
- patient role
WHO (1948) concept of health
Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity
–> revolves around the concept of health
–> ‘system’ way of thinking ad reasoning
narrative
a story (=series of related events) told among humans to explain a principle, belief or thought
What is a system?
Multiple elements that interact and result in a situation, outcome, goal, other
Multiple elements (static, dynamic, behavioral) that interact (constantly chance) and result in a situation, outcome, goal, other
healthcare system around the patient
- patient as a person
- immediately surrounding healthcare
- healthcare system
- health system
Patient-centered care and systems approach
system: taking all elements that are important to reach a certain goal into account
in healthcare: all elements that matter in a patient’s well-being
Or otherwise framed: all elements that impact the patient
Patient-centered care/ personalized medicine/ precision medicine
- focus on well-being (what matters to you and how can we help?)
- context: take social context (work, family, network) and situation (life stage, live events, financial) into account
- different patient role: who is where and when in the lead? what does autonomy do, and mean for patient?
Levels (micro, meso, macro)
- Micro: the patient as a human being: strengths, vulnerabilities, preference
- Mese: family, friends, community, daily interactions such as work, profession, faith and beliefs
-Macro: circumstances that patients lives and has lived in, including ‘social determinants of health’
Social determinants of health (WHO)
the conditions in which people are born in, grow, live, work and age. These circumstances are shaped by the distribution of money, power, resources
- economic stability
- social and community context
- neighborhood and environment
- health care
- education
paradigm/ paradigma
an establish (accepted) story or set of stories (narratives)
Paradigm shift: in the situation that an established story changes
System perspective
perspective that tries to comprehend all component and their interactions that matter for the actual health
Mapping and modeling
to get a better understanding of a process, a system, or an interaction between different components, visual diagrams can be used
Map: more often used for simple representation of reality
Model: for more complex, layered or dynamic representation of reality
what is the purpose of modeling
- Modelling is a goal to understand & clarify processes
- A model is a deliberately chosen selection of reality
- A model depends on the perspective and aim of the modeller
- So, do not mistake a model for reality
Modelling is an aid to innovation
- Models can assist in finding the right treatment | innovation | policy | other by identifying leverage & friction points.
- But they can obscure matters that are important as well
- A model is a simplification of reality and subject to modellers’ choices.
- So always remain aware of the model’s objective, perspective and subjectives
objective
goal; in the context of health system modelling: the question to what goal the model is designed
perspective
point of view, position in the context of health system modelling: from whose point of view (patient, care provider)
subjectives
influenced by or based upon: in the context of health system modelling: the elements or outcomes that are likely influenced by the modelling techniques or modellers’ choices and are therefore open to interpretation
Elements in modelling
static elements, dynamic elements, behavioral elements
static elements
unmoving things that nevertheless influence system dynamics, such as the environment (building, interior design)
dynamic elements
circumstances that change over time, such as computer systems, climate, day/night fluctuations, but do not exhibit behaviors. (maar geen gedrag vertonen)
behavioral elements
actors that show behaviors –> humans
Actors
an element that participates in a system, that has a role (can both be things or persons)
stakeholders
behavioral elements that have interest in systems outcomes, who can be affected or impacted
- relatives of the patient
- investment partners healthcare providers
health system
a health system consists of organizations, people and actions whose primary intent is to promote, restore or maintain health
General speaking, the health system boundary is a country
compare health systems (inputs/processes)
inputs/processes
- Payor/Provider mode: Those who pay for care, and those who provide the carel
- Expenditure dedicated to healthcare: how much money spent on providing healthcare to the total population, either as a total, or as a % of national expenditure.
- Infrastructure: Indicators such as the number of hospitals per region or capita, number of beds per hospital, No. of hospitals
- Personnel: type of medical specialists, number of healthcare workers per region, traditional healers, etc.
- Access to care: Distance to nearest hospital, care provider, etc. Access to medicines/equipment/supplies
- Health culture & norms: preference for traditional healing methods, trust in government provision of public health
compare health systems (output/outcomes)
- Patient outcomes:e.g. for individual diseases
- Morbidity/mortality rates
- Infant morbidity/mortality
- Patient experience
- Quality/safety (including all 7 dimensions)
zorgstelselwetten
- zorgverzekeringswet
- wet langdurige zorg
- wet maatschappelijke ondersteuning
- jeugdwet
- wet publieke gezondheid
financial regulation
-zorgverzekeraars Nederland
- zorginstituut nederland
- zorgkantoren
- gemeenten (municipality)
- SVB (Sociale Verzekeringsbank)
governors in healthcare
institutional
- raad van toezicht
- klachten commissie
external
- governance (formal regulatory institutions)
- professional associations
- steakholders groups
what is there to govern
- Quality and safety
- privacy and data security
- specific domain-related dangers
- Dutch situation: market function on topics such as accessibility, competition, preventing free market excesses
Autoriteit consument en markt (ACM)
- cooperation vs compitition care providers (monopoly)
- consumer rights
Nederlandse zorgautoriteit (NZA)
- Accessibility
- Affordability
- financial flow check
- Domains: Zvw en Wlz
inspectie gezondheid en jeugd (IGJ)
Quality and safety
Knowledge actors
Knowledge institutions: Organisations that generate knowledge
- Universities & academic medical centres
- Institutions organised around a disease (cancer), a skill (health data centers) or function (policy)
- Institutions steering knowledge generation (e.g. through grants)
- National Healthcare Institute (|zorginstituut)
Advisory bodies: Boards consisting of experts who advise the government on policy (permanent and ad hoc)
Medical professional organisations: act in permanent and ad hoc advisory boards, answer to concerns and anticipate on expected developments (both requested and unsolicited advice)
Financial sources
Primary cash flow |eerste geldstroom
Direct financing universities and academic centers
Secondary cash flow |tweede geldstroom Governmental funds (NWO, ZonMW, NHCI)
Tertiary cash flow |derde geldstroom
Private and public-private foundations
andere actoren
Kennisinstituten overheid
- Zorginstituut Nederland
- NWO
- ZonMw
Internationale Overheid
- European Comission
Foundations
- Nierstichting
- Hersenstichting
- Hartstichting
- Federatie Medisch Specialisten
Kennisinstituut
Health insurers initiatives
- CbusineZ
- De huisarts bij je thuis
Sugar daddy funds
- Bill & Melinda Gates
- Open Society
Commercial funds
- Global Health Innovation
Public-private collaboration funds
- Health Innovations
social determinants of health: economic stability
resources essential to a healthy life
- home (affordable)
- work (work environment)
- food (access and nutrition)
- transportation (connection to work and school)
social determinants of health: social and community context
context in which people live, learn, work and play
- Neighborhood, town, region, country
- schools
- work environment
social determinants of health: physical environment
Environment in which people live, learn, work and play
Environmental hazards: events or substances in man-made environment or ecological system, that may cause adverse consequences for humans beings
- Chemical (such as poisons or pollution)
- Biological (mainly microbiological hazards (a virus etc))
- Physical (weather conditions, flood risks, earthquakes, UV exposure, electrical etc.)
- Psychological (aggression, intimidation, uncertainty/instability, etc)
social determinants of health: education
Effects of education on health, by
- Education resulting in higher job satisfaction and income (link to economic stability)
- Health awareness, such as reflected in child vaccination rates
- Health behaviours, such as in smoking, food habits, risk-taking behaviours
- Health knowledge, such as in abilities and skills (e.g. hygiene, when to call a doctor etc.)
- Healthcare access (understanding the system)
social determinants of health: heathcare
How does health care contribute to health?
By caring for patients or curing disease
What determines its effectiveness on a national level?
- Availability or presence and Accessibility
- Quality & Safety of care delivery
- Proportion preventative care versus reactive care
constitution
- Art 11 Recht op onaantastbaarheid lichaam
- Art 22 De overheid moet maatregelen treffen om de volksgezondheid te bevorderen
Wet Geneeskundige behandel overeenkomst (WGBO)
Law on agreement in medical treatment’: a law on rights and obligations in the relationship between doctors and patients
An agreement in judicial terms means, both parties can agree on anything the want to.
This is different in healthcare, because an unequal relationship exists
The patient
Must explicitly consent to treatment, unless they are ‘not capable of giving consent’.
Right on information
Right on privacy
Can terminate the agreement
The doctor
Bound to professional standards (including refusal of procedures or treatments that a patient may demand)
Cannot terminate the agreement (but can refer)
Dwang in zorg (Compulsory care)
Two Dutch laws on compulsory care:
- Compulsory Psychiatric Care | Wet verplichte geestelijke gezondheidszorg
- Care & Compulsion Act | Wet zorg en dwang
- Acute need for compulsory care = placement in custody | Inbewaringstelling (IBS)
- Not-acute need for compulsory care = judicial authorization | Rechterlijke machtiging (RM)
scientific research on humans or bodily tissues
- Medical scientific research act –> WMO –> all scientific research that involves humans, must be reviewed by a medical ethical board
- Embryowet –> not forbidden, but bound to strict rules
- Orgaan en weefsel transparatie wettem –> 3 wetten that regulate organ and tissue donation
- privacy en persoonsgegevens –> generic law that is strictly adhered to in healthcare
wetten innovations: medicine and medical devices
EU MDR –> european law regulating admissions of medical devices sinds 05/2021
Europees Medicijn Agentschap (EMA) en college ter beoordeling geneesmiddelen (CBG) –> the European and dutch boards deciding on admission of new medicine
Wet BIG (Beroepen individuele gezondheidszorg)
- Register protected professional titles
- Defines restricted actions / proceedings
- Professional confidentiality
- Disciplinary law, court contains
- three colleagues
- two jurist
Case submission can be done by: - Patients and relatives
- Health and youth inspectorate
medisch tuchtrecht
Bijzondere rechtspraak in specifieke beroepen die het algemeen belang dienen.
De gronden voor ontvankelijk zijn van een klacht (alg: onprofessioneel en/of onzorgvuldig handelen)
˗ Ondermijnen van het vertrouwen in de stand der geneeskundigen.
˗ Nalatigheid waardoor ernstige schade ontstaat.
˗ Blijk geven van grove onkunde
Maatregelen tuchtcollege
a. Waarschuwing
b. Berisping.
c. Geldboete (max)
d. Schorsing (evt. samen met geldboete)
e. Gedeeltelijke of gehele ontzegging het beroep uit te oefenen
safity science
- Born out of disasters (big and small scale)
- A necessity to make further technological progress
- Integrating various knowledge-domains (technical, psychological, social, design)
- If it is successful, nothing happens…
Thinking ahead
anticipate on hazards that are present, the risk they pose and how to prevent or mitigate these
Determinisme
Philosophical concept, starting that all events have a pre-determined cause, that nothing is random.
Hazard
a source of energy that has the potential to cause harm to a target
Risk
the chance a hazard impacts a target and the severity of that impact
(sentinel) event
the moment the hazard hits the target
impact
the severity of consequences when a hazard hits a target
prevention
taking measures that result in the hazard not impacting the target
mitigation
minimizing the severity of the damage resulting from the hazard impacting the target
scenario
a sequence of events, including influences from the environment (=conditions)
conditions
the circumstances that (potentially) influence a process. When there are expected to have a negative impact, these are also called latent failures
failure
when a danger results in harm
cascading effects
when each event triggers a next scenario
barriers
are measures that prevent the agent to impact the host, or mitigate the consequences of the impact
safe by design
Mechanical properties: in design, materials, durability, maintenance requirements etc
Human – innovation interaction: impact on human using it | intended use versus actual use | design favouring ‘safe acts’ | ‘side-effects’ such as distraction or blind spots, influencing human performance. | etc. etc.
Imbedding in the organisation: how does the innovation fit in (potential collisions, timing etc) | can the innovation be maintained? | How is its use and implementation communicated | etc etc
knowledge
- Systems sciences studies the outcome of interactions between multiple components. This leaves the integrity of reality (better) intact and is thus likely more realistic.
- Building models opens a possibility to simulate situations and observe the effects of experimenting (on a smaller scale, incremental and multifaceted; ergo, no silver bullets).
- fundamental
- translation
- applied
Evidence based medicine approach
A method to evaluate knowledge in medicine
- defining the problem/ clinical question –> assess, Ask,
- search literature –> Acquire
- critical appraisal of evidence –> Appraise
- implement –> apply
- Accept
bias
A disproportionate weight against/in favor of.. or skewed representation of.. due to mostly unconcious processes or unnoticed flaws in research design
