Understanding the Healthcare System: Nurses, Practitioners, and Patient Care Dynamics

1. Nurses • Registered Nurses - real nurses • LPN - licensed practical nurses • Nurse Practitioners • non-licensed caregivers

2. Nurse-Patient Relationship • Nurses are independently licensed • Nurses have an independent duty to patients • Nurses exercise independent judgment

3. 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

4. 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

5. 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

6. Nurse Extenders • lower level care providers • medical assistants, surgery technicians, lab technicians • on the job training vs certification

7. 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

8. 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

9. 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

10. STRUCTURE OF HEALTH SYSTEMS 20 February 2009

11. WHAT IS HEALTH ? • A STATE OF COMPLETE PHYSICAL, MENTAL AND SOCIAL WELL-BEING, NOT MERELY THE ABSENCE OF DISEASE • WORLD HEALTH ORGANIZATION

12. 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

13. PUBLIC HEALTH VS PERSONAL HEALTH • PUBLIC HEALTH - TO IMPROVE THE HEALTH OF A POPULATION • PERSONAL HEALTH - TO IMPROVE THE HEALTH OF THE INDIVIDUAL

14. US PUBLIC HEALTH SYSTEM • Local System – very political • Governed by Boards of Health • Health Officer/Director

15. HEALTH DEPARTMENTS • Environmental Management • Vectors • Water quality • nuisances • Disease Control • Clinics • Epidemiology • Personal Health Services

16. PREVENTION • PRIMARY - PREVENTION OF DISEASE • SECONDARY - PREVENTION OF CONSEQUENCES OF DISEASE • TERTIARY - PREVENTION OF DEATH OR DISABILITY

17. 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

18. INTEGRATED ORGANIZATIONS • HOSPITALS, PHYSICIANS, INSURERS, AND PURCHASERS FORM VERTICALLY AND HORIZONTALLY INTEGRATED ORGANIZATIONS • IN OTHER CONTEXTS THESE ARE CALLED MONOPOLIES

19. 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

20. VERTICAL INTEGRATION • LINKING ORGANIZATIONS SO THAT SUCCEDING TRANSACTIONS STAY WITHIN THE SYSTEM • MEDICAL EXAMPLE • OCHSNER CLINIC • MONOPOLY EXAMPLE • STANDARD OIL

21. 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

22. TRIAD OF GOVERNANCE • Governing Body • CEO • Professional Staff Organization

23. Hospital Medical Staff • Bylaws are the structure • Not like corporate bylaws • Licensed Independent Practitioners • Their contract with the hospital

24. 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

25. Credentialing • Prove training and experience • National Practitioner Data Bank • Major liability for the hospital

26. 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

27. Management Skills • There is special training for healthcare administration • Getting an MD or a BSN does not make you too stupid to learn this