CHAPTERS 14 & 15Code Blue Health Science Edition 4

There is evidence that some doctors who own labs or x-ray facilities have, at times, ordered unnecessary tests to increase their personal income.

There is evidence that unnecessary surgery has often been performed to increase surgeon’s income.

There is evidence that when hospital occupancy is low, that administrators can often successfully pressure doctors to:o Admit more patients (patients that might have been

treated in the doctor’s office or in an outpatient clinic), or

o Increase the length of time they keep the patient in the hospital.

Under fee-for-service, gaming the system was possible because . . .o The more products and services the physicians ordered

for patients, the more revenue doctors and hospitals generated.

o Patients had little or no control over what procedures they purchased.

o Someone else (the insurance company or government) was paying the bill.

The proposed solutions we are going to discover involve:o Managing care so that payment is based on outcomes (if

the patient gets well), rather than what products and services are provided

o Establishing better systems for review of the way physicians practice medicine

o Providing more incentives for doctors to provide preventive medical care, which lowers costs

o Paying doctors in a way that encourages them to efficiently use medical resources while curing the patients

o Managed careo National Health Insurance

APPENDIX TO CHAPTER 15

Note to teachers and students. The author used the national health skill standards developed as a pilot project by the U.S. Department of Labor in determining what topics should be included in Code Blue.

A test on these standards leading to a Healthcare Foundation Skills Certificate can be taken by students wishing this certification (www.nocti.org).

After completing Code Blue, the author took the exam and felt that all of the skill standards were covered in sufficient detail in this textbook/novel, except for systems.

While the author did not write Code Blue to provide specific answers found on the test, systems is such a broad area that it felt advisable to add an appendix focusing specifically on those systems topics NOCTI felt relevant for the exam.

Although this appendix was written specifically for students interested in taking the test, the material should be useful to any health occupations student.

Appendix to chapter 15

A system is an orderly and complex arrangement of parts.

There are many types of systems including:o Physiological systems: the digestive

system, the neurological system, and the circulatory system

o Economic systems: capitalism and socialism

o Computer systems: network, mainframe, and PC computer systems

Most systems have the following elements:o Input – resources entering the systemo Throughput – the processes and resources used to

create a producto Output – the final producto Feedback – information taken from the output to control

or correct errors in throughput

Systems thinking is one approach to problem-solving.

It is also known as systems analysis.

Systems thinking is a way of solving problems by looking at a problem from a broad perspective, looking not only at the individual parts of the system, but also at the way these parts relate to each other.

Systems thinking recognizes the whole is greater than the sum of its parts, and often results in different conclusions than those reached by traditional problem-solving models.

The American healthcare delivery industry is a system.o System components include doctors, hospitals,

insurance companies, and so on.o In addressing problems within the healthcare delivery

system, it is important to look at the system as a whole, and not just focus on one or more of its components.

Systems thinking involves backwards thinking. It begins with the final goal and works backwards,

analyzing the relationship of each part or activity to the goal.

For example, if the goal of a team is to produce low-cost, yet high-quality medical products, then backwards thinking starts with the final product, and evaluates each input and activity involved in producing the product.

Globalism: It provides a global approach to problem-solving. o Systems thinking helps employees “see the forest for

the trees.” o It enables team members to see the big picture.

Focus: Systems thinking allows problem solvers to identify cause and effect relationships.

It focuses on the activities needed for change.

Team building: Systems thinking helps team members identify the goal of the team, and understand how their individual activities contribute to that goal.

Human resources include the professionals who diagnose and treat the patients.

Financial resources are the funds to pay the salaries of the healthcare workers.

Patients, of course, are the people who enter the system for diagnosis, treatment, and so on.

By this, we mean the individuals, insurance companies, government agencies, and so on, who must pay the bills.

Self payment—some patients pay their own doctor and hospital bills.

Employers—many companies provide health insurance.

Private insurance—some people buy their own health insurance coverage.

Government insurance—Medicare, Medicaid and, soon, the subsidies provided by the Patient Protection and Affordable Care Act.

Outputs includeo Healthy patientso Healthy lifestyles

Movement or pressure exerted on one component exerts pressure on others.

Pressure to cut cost, for example, affects the volume of patients entering the system.

Greater volumes of patients entering the system puts pressure on finance mechanisms such as Medicare and Medicaid.

More resources spent preventing illness will cut resources needed for diagnosis and treatment.

Staff shortages can raise wages and put pressure on financing mechanisms.

The healthcare industry is a complex system of many parts.

It is impossible to change one part of the system without influencing others.

Historically, some people have attempted to fix the system by focusing on one or more broken parts.

By failing to take a systems approach and failing to consider the big picture, however, they often reap unintended consequences.

Those wishing to address quality, cost, and accessibility must adopt a systems approach to problem solving.