
Healthcare Systems Engineering
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Chapter 1
The Healthcare Delivery System
"In nothing do men more nearly approach the gods than in giving health to men."
-Cicero
Overview
Health care (or healthcare) is the maintenance or restoration of the human body by the treatment and prevention of disease, injury, illness and other physical and mental impairments. Healthcare is delivered by trained and licensed professionals in medicine, nursing, dentistry, pharmacy, and other allied health providers. The quality and accessibility of healthcare varies across countries and is heavily influenced by the health policies in place. It is also and dependent on demographics, social and economic conditions.
A health system (healthcare system or health care system) is organized to facilitate the delivery of care. The World Health Organization (WHO) defines health systems as follows:
A health system consists of all organizations, people and actions whose primary intent is to promote, restore or maintain health. This includes efforts to influence determinants of health as well as more direct health-improving activities. A health system is therefore more than the pyramid of publicly owned facilities that deliver personal health services. It includes, for example, a mother caring for a sick child at home; private providers; behavior change programs; vector-control campaigns; health insurance organizations; occupational health and safety legislation. It includes inter-sectoral action by health staff, for example, encouraging the ministry of education to promote female education, a well-known determinant of better health. (Everybody's Business: Strengthening Health Systems to Improve Health Outcomes. WHO's Framework for Action, 2007)
WHO goes on to say that:
A good health system delivers quality services to all people, when and where they need them. The exact configuration of services varies from country to country, but in all cases requires a robust financing mechanism; a well-trained and adequately paid workforce; reliable information on which to base decisions and policies; well-maintained facilities and logistics to deliver quality medicines and technologies. ("World Health Organization. Health Systems," n.d.)
1.1 Healthcare Delivery Components
The delivery of healthcare to a patient population depends on the systematic provision of services. WHO suggests that "People-centered and integrated health services are critical for reaching universal health coverage. People-centered care is care that is focused and organized around the health needs and expectations of people and communities, rather than on diseases. Whereas patient-centered care is commonly understood as focusing on the individual seeking care (the patient), people-centered care encompasses these clinical encounters and also includes attention to the health of people in their communities and their crucial role in shaping health policy and health services. Integrated health services encompass the management and delivery of quality and safe health services so that people receive a continuum of health promotion, disease prevention, diagnosis, treatment, disease-management, rehabilitation and palliative care services, through the different levels and sites of care within the health system, and according to their needs throughout the life course."
Table 1.1 summarizes the major types of levels and sites of care components and gives some examples of providers and the conditions they address. While there is no universal definition of each type, there is some consensus in usage (except where specifically noted). Improvement of the healthcare system will depend on the provider professionals performing as a team that can act and influence patients as they may transition from one care delivery mode to another.
Table 1.1 Delivery of Healthcare Services
Type Delivery Focus Providers Conditions/Needs Primary care- Day-to-day healthcare
- Often the first point of consultation for patients
- Primary care physician, general practitioner, or family or internal medicine physician
- Pediatrician
- Dentist
- Physician assistant
- Nurse practitioner
- Physiotherapist
- Registered nurse
- Clinical officer
- Ayurvedic
- Routine check-ups
- Immunizations
- Preventive care
- Health education
- Asthma
- Chronic obstructive pulmonary disease
- Diabetes
- Arthritis
- Thyroid dysfunction
- Hypertension
- Vaccinations
- Oral health
- Basic maternal and child care
- Treatment of acute and chronic illness and injury provided in a dedicated walk-in clinic
- For injuries or illnesses requiring immediate or urgent care but not serious enough to warrant an ER visit
- Typically do not offer surgical services
- Family medicine physician
- Emergency medicine physician
- Physician assistant
- Registered nurse
- Nurse practitioner
- Broken bones
- Back pain
- Heat exhaustion
- Insect bites and stings
- Burns
- Sunburns
- Ear infection
- Physicals
- Consultation, treatment, or intervention on an outpatient basis (medical office, outpatient surgery center, or ambulance)
- Typically does not require an overnight stay
- Internal medicine physician
- Endoscopy nurse
- Medical technician
- Paramedic
- Urinary tract infection
- Colonoscopy
- Carpal tunnel syndrome
- Stabilize patient for transport
- Medical specialties typically needed for advanced or acute conditions including hospital emergency room visits
- Typically not the first contact with patients; usually referred by primary care physicians
- Emergency medicine physician
- Cardiologist
- Urologist
- Dermatologist
- Psychiatrist
- Clinical psychologist
- Gynecologist and obstetrician
- Rehabilitative therapist (physical, occupational, and speech)
- Emergency medical care
- Acute coronary syndrome
- Cardiomyopathy
- Bladder stones
- Prostate cancer
- Women's health
- Specialized highly technical healthcare usually for inpatients
- Usually patients are referred to this level of care from primary or secondary care personnel
- Surgeon (cardiac, orthopedic, brain, plastic, transplant, etc.)
- Anesthesiologist
- Neonatal nurse practitioner
- Ventricular assist device coordinator
- Cancer management
- Cardiac surgery
- Orthopedic surgery
- Neurosurgery
- Plastic surgery
- Transplant surgery
- Premature birth
- Palliative care
- Severe burn treatment
- Advanced levels of medicine that are highly specialized and not widely accessed
- Experimental medicine
- Typically available only in a limited number of academic health centers
- Neurologist
- Ophthalmologist
- Hematologist
- Immunologist
- Oncologist
- Virologist
- Multi-drug-resistant tuberculosis
- Liver cirrhosis
- Psoriasis
- Lupus
- Myocarditis
- Gastric cancer
- Multiple myeloma
- Ulcerative colitis
- Professional care in residential and community settings
- End-of-life care (hospice and palliative)
- Medical director (physician)
- Registered nurse
- Licensed practical nurse
- Certified nursing assistant
- Social worker
- Dietitian or nutritionist
- Physical, occupational, and speech therapists
- Post-acute care
- Disease management teaching
- Long-term care
- Skilled nursing facility/assisted living
- Behavioral and/or substance use disorders
- Rehabilitation using prosthesis, orthotics, or wheelchairs
While Table 1.1 shows delivery types as distinct, in practice there is often overlap and intersection. Primary care can be delivered in urgent care settings (e.g., walk-in clinics). Emergency rooms may often be the de facto provider of primary care. Similarly, quaternary care may be an extension of tertiary care.
The International Classification of Primary Care, Second Edition (ICPC-2), is a reference (accepted by WHO) that allows classification of the patient's reason for encounter (RFE) with primary care or general care ICPC-2). The classification structure addresses the problems or symptoms/complaints, infection, injuries, diagnosis managed, and interventions. It also codes processes...
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