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VOLUME 11 • ISSUE 1 / 2009 • March / April• €15

OF F I C I A L J OURNAL O F THE EUROPEAN ASSOC IAT ION OF HOSP I TAL MANAGERS

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As with our European neighbours, the Frenchhealth system has been facing serious challengesfor several years. Naturally, these have taken avariety of forms, but they all have the same ori-gins: the increasing scarcity of medical humanresources, a very high increase in health expendi-ture coupled with large budgetary cons traints, andthe difficulty of reconciling the necessary proxim-ity of health establishments with the demands forcare safety, which requires a concentration of careteams and technical support centres.

Since being elected as President of France, NicolasSarkozy has expressed his will to propose a reor-ganisation of the French health system. Thus, asthe result of extensive dialogue, the HPST bill(Hospital - Patient - Health - Territory) was pre-sented to hospitals.

Inspired by conclusive experiments carried outacross Europe in recent years, this bill will beexamined throughout the course of the first halfof 2009 by the Parliament of France and shouldintroduce some major changes:

In the first instance, the bill aims to redefine thenotion of public services in hospitals by specify-ing that all health establishments, be they publicor private, can assure these operations. The gov-ernment’s goal is to make everyone bear theresponsibility and limitations of these public serv-ice operations, and thus to grant the system bet-ter efficiency.

The other main motivation is in introducing theidea of a “health territory” and in creating territori-al hospital communities, a formal structure forcooperation between public establishments withinthe same territory. While retaining their legal auton-omy, several establishments in the same zone willthereby be incited to define a joint strategy, sharetheir human resources, concentrate their technicalsupport centres in the same place and so on.

Alongside this increased territorialisation,regional health agencies (ARS) will be set up asof January 2010. Given tasks and powers greaterthan those of the current Agences Régionales del’Hospitalisation, the regional health agencies willbe required to define and implement a regionalhealth policy, be it hospital policy, public healthpolicy, outpatient care, or medico-social policy.Announced several years ago, these new agen-cies should allow the hospital and non-hospitalsector to better complement one another.

Finally, the new law should generate innovationsin the internal management of health establish-ments: the in-depth development of decision-making bodies within hospitals, reinforcement ofthe powers of the managers of the establish-ments, a strengthening of the role of medicalactivity clusters and their competences, as wellas the creation of new types of work contractsaimed at improving hospital careers, notably bymaking it possible to link remuneration to the indi-vidual performance of actors in the health system.

In this climate of profound change, it is more cru-cial than ever that every hospital decision-maker isinspired by the measures taken in other states toface similar problems. This is why, in 2009, theEAHM intends to invest a great deal of energy intothis mission to bring actors in the field of Europeanhospitals together; it is only in doing so that wecan work, step by step, towards a Europe of robustand coherent health services.

Wishing you all a superb 2009!

Paul Castel, President of the EAHM

Paul Castel

Editor-in-Chief and Publisher, Secretary-General of the European Association of Hospital Managers

Willy [email protected]

European Association of Hospital ManagersGeneral Secretariat32 Bvd du Jardin Botanique, B-1000 BrusselsTel.: +32 (2) 733.69.01Website: http://www.eahm.eu.org

Executive Committee of the EAHM Board Members

Paul Castel, President, [email protected] Kölking, Vice-President, [email protected] Delgado, [email protected] Mieczyslaw Pasowicz, Vice-Pdt, [email protected] Hansen, [email protected]

Other Members of the Executive Committee

Nikolaus Koller, Austria ,[email protected] Iemants, Belgium, [email protected] Muskurova, Bulgaria, [email protected] Herman, Croatia, [email protected] Tuomola, Finland, [email protected] Hédouin, France, [email protected] Hodgetts, Great Britain, [email protected] Roumeliotis, Greece , [email protected] Lajos Ari, Hungary, [email protected] O’Dwyer, Ireland, [email protected] Sverrisson, Iceland, [email protected] Luigi d’Elia, Italy, [email protected] Gendvilis, Lithuania, [email protected] Hastert, Luxembourg, [email protected] Aghina, Netherlands, [email protected] Normann, Norway, [email protected] Juraj Gemes, Slovakia, [email protected] Rudi Turk, Slovenia, [email protected]

Gianluigi Rossi, Switzerland, [email protected] Yildirim, Turkey, [email protected]

Editorial Board

Heinz Kölking, Pdt, Germany, [email protected] Juraj Gemes, Slovakia, [email protected] Duque Duque, Spain, [email protected]çois Godard, France, [email protected]. Jacques Massion, Belgium, [email protected] Hradsky, Austria, [email protected] Marie O’Grady, Ireland, [email protected]

Managing Editor

Caroline Hommez, [email protected]

Editors

Lee Campbell, Catalina Ciolan, Wendy Genar, Dominic Gilmore, Sonja Planitzer (SP), John Sanders, Rory Watson, Jos van Landuyt, Christiane v. Ludwig, Mirjam Moltrecht, Christoph Mierau

Guest Authors

Janina Asadauskien, Edmundas Baltakis, M. Bernardo, Susan Burnett, Gediminias Cerniauskas, Edwin Claridge, M. DeSemir, Alexander Dobrev, Stasys Gendvilis, J. Gene-Badia, I. Grau, Jean Herveg,Andrew Hoole, Tom Jones, Bruno Marchal, Gerda Sailer, E. Sanchez Freire, Josef Smolen, Wilhelm Strmsek, Karl Stroetmann, Anne-Marie Teller, Thilo Ullrich, Pascale Witz

© (E)Hospital is published five times a year. Publisher is to be notified ofcancellations six weeks before end of subscription. The reproduction of (parts of) articles is prohibited without consent of the pub-lisher. Opinions expressed in technical articles are the views of the authorsalone. The publisher does not accept liability for unsolicited materials. Thepublisher retains the right to republish all contributions and submitted materialvia the Internet and other media.

The Publishers, Editor-in-Chief, Editorial Board, Corres pondents and Editorsmake every effort to see that no inaccurate or misleading data, opinions orstatements appear in this publication.All data and opinions appearing in the articles and advertisements herein arethe sole responsibility of the contributor or advertiser concerned. Thereforethe Publisher, Editor-in-chief, Editorial Board, Correspondents, Editors andtheir respective employees accept no liability whatsoever for the conse-quences of any such inaccurate or misleading data, opinions or statements.

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FRENCH HEALTH SYSTEMUNDERGOES A TRANSFORMATION

The editorials in (E)Hospital are writ ten by leadingmembers of the EAHM. How ever, the contributions

publish ed here only ef lect the opinion of the authorand do not, in any way, represent the official po sition of the EuropeanAs so ciat ion of Hospital Managers.

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Editorial

NEWS

EAHM

National

Europe

EU Affairs

HUMAN RESOURCES: STAFF RETENTION

Falling Numbers of Health Workers: Facing the CrisisBy Bruno Marchal

Outsourcing in HospitalsBy Thilo Ullrich

Modification of Working Hours of Nursing Staff in Oncological SurgeryBy Anne-Marie Teller and Pascale Witz

Dual Management at the Department LevelBy Josef Smolen, Gerda Sailer and Wilhelm Strmsek

E-HEALTH

E-Health InvestmentBy Alexander Dobrev, Tom Jonesand Karl A. Stroetmann

ICT Usage in the Hospital EnvironmentBy Jean Herveg

Forum Clinic By I. Grau, J. Gene-Badia, E. Sanchez Freire, M. Bernardo and M. DeSemir

Patient Safety and E-HealthBy Susan Burnett

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Human Resources

Our human resources dossier revolvesaround attraction and retention of staffand contains two theoretical articles,along with two more practical imple-mentations. Dr Marchal reminds us thatmoney is not the only incentive at ourdisposal to enhance motivation andcommitment of our staff, as illustratedby magnet hospitals. Mr Ullrich analysesthe impact of hospital outsourcing onlabour regulations. On the other hand, aParis hospital unit has decided to modi-fy nurses’ working shifts from 8 to 12 hours,to the great satisfaction of both staffand patients. And an often very trouble-some relationship between two hospitalprofessional groups, i.e. doctors andnurses, is being worked out in Viennahos pitals towards a balanced dual man-agement of the department.

E-Health

Hospital managers sometimes get thefeeling that they have seen it all, read itall about e-health. That’s why this issuefocuses on seldom considered aspectsof e-health: the financial one, with anarticle dealing with investment rationalebehind e-health projects, but also thelegal one, with Professor Herveg review-ing all the different legal questions re -volving around ICT applications within ahospital. Susan Burnett gives us somevivid, and probably familiar, examples ofthe tight relationship between e-healthand patient safety. Our dossier ends witha very innovative Spanish e-health proj-ect, which highlights the need for pre-ventive healthcare and the essentialinteraction with chronic patients.

MEDTECH

Should we Buy an OncologyManagement System?By Andrew Hoole and Edwin Claridge

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FOCUS: LITHUANIA

The Lithuanian Health SystemBy Gediminas Cerniauskas and Janina Asadauskien

Recent Changes in LithuanianHospital ActivitiesBy Edmundas Baltakis

The Association of Hospital Managers PhysiciansBy Stasys Gendvilis

FRENCH

Editorial

AEDH News

Executive Summaries

GERMAN

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EKVD News

Executive Summaries

AGENDA

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Focus: Lithuania

During the last five years Lithuania has had one of the high-est economic growth rates among EU candidate and mem-ber countries, reaching 10.2% in 2003 and 8.9% in 2007.

Starting from 1 January 2009 special health contributionsat the level of 6% will replace allocations from general in-come tax. The change will mean that about 75% of statu-tory health insurance revenues will be generated by healthinsurance contributions (HIC) and 25% by contributions fromthe state budget and other sources of marginal importance.The relative increase of importance of HIC means that thesystem is moving closer to the Bismarck model but certaindifferences remain.

In 2003 the government of Lithuania adopted a resolu-tion on the restructuring strategy of healthcare facilities.Two phases were provided for the restructuring of health-care establishments, the first period in 2003-2005, andsecond in 2006-2008.

During the restructuring process, specialised units were closedin many municipal and regional hospitals, and theses serviceswere transferred to the specialist sections of district and uni-versity hospitals. The number of inpatient institutions fell by asmuch as 44.4%. There are now plans to facilitate the infra-structure of consultative outpatient facilities and emergencydepartments, and to develop outpatient rehabilitation servic-es, day hospital and day surgery.

The Association of Hospital Managers Physicians of Lithuaniawas founded in 1991. In 1996 during the EAHM Congress in Tam-pere (Finland), our association was accepted as a member.

Editor’s note

This article was written before the recent economic prob-lems in Lithuania.

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Last year, our Danish sister organisa-tion, the Dansk Selskab For Ledelse ISundhedsvæsenet, decided to createan international sub committee. The aimwas to promote the exchange of know l-edge and experiences with the inter-national community; to follow in terna-tional developments in healthcaremanagement and bring Danish expe-riences to the international context(see (E)Hospital 2008/5).

As a starting point, last December, aDanish delegation of 14 people travelled

to Brussels combining several visits. On theagenda was a visit to the European Parliamentwith the Danish MEP Karin Riis-Jorgensen and ameeting with the European Com mission. Therewas also a meeting with the Danish representa-tion in Brussels and in particular with the Danishregional representatives.

Combined with a visit to the Clinique Saint-Jean/Kliniek Sint-Jan, the EAHM welcomed thedelegation to its office. The group was intro-duced to the activities of our associations aswell as the policy issues currently high on theEuropean agenda.

The draft Directive on patients’ rights and cross-border care offered the opportunity to discussquality of care. The contribution that an accred-itation model can make to quality was also dealtwith, in line with the 2007 EAHM seminar on thesubject. The theme of privatisation, and the co-existence of public and private stakeholders onthe European hospital scene is high on the health-care agenda as well and will be the main topic ofthis year’s EAHM seminar (see agenda). Danishand European visions on hospital governance wereshared during this meeting, in the light of the recentbanking crisis and the stormy relationship betweenhospital management and providers.

N E W S F R O M T H E E U R O P E A N A S S O C I AT I O N O F H O S P I TA L M A N A G E R S>

DANISH DELEGATION VISITS BRUSSELS



A D V E R T O R I A L



Population growth and the consequentchallenges for the healthcare sector wasthe aptly chosen theme of the SeventhTraining Conference for Hospital Managersheld in Vienna in November 2008.

The proportion of the population aged 65years and over is increasing worldwide. Ac-counting for only 5% of the population in1950 and 7% in 2000, the number of peo-ple in this age group is expected to rise to1.5 billion or 17% of the global populationby 2050, with Europe and Japan expectedto be disproportionately affected. While thistrend is ostensibly positive, the ageing ofthe population raises questions for socie-ty in general, for instance, in employment,and health systems in particular. Anotherissue arising from demographic change isthe increasing proportion of migrants in thepopulation, some of whom come from aliencultures. While the phenomenon is com-mon to all European countries, in Austria itis most marked in Vienna.

The Congress Organiser

The Association of Hospital Managers ofVienna, also known by its old-fashioned ti-tle, the Working Group of Administratorsof Health and Welfare Institutions of Vi-enna, was founded in 1956 (1). It is a mem-ber of the Federal Conference of AustrianHospital Managers or BUKO as it is com-monly known (2). The Vienna Hospital Man-agement Congress has been held bienni-ally since 1996 when it was first organisedto mark the 40th anniversary of the found-ing of BUKO (3). The 2008 Congress tookan in-depth look at population growth ina series of presentations and workshops.

The Future of Healthcare in the“Silver” Society

This was the title of a powerful opening ad-dress given by Jeanette Huber of the Fu-ture Institute (Zukunftsinstitut GmbH in

Germany). Ms Huber mapped out severalso-called megatrends of the future, in-cluding the healthcare revolution and the“silver” revolution. As people live longerand more active lives than their forefa-thers, the number of older people in theworkplace increases. Although this grouptakes personal responsibility for its healthand well-being and values individualitymuch more than earlier generations, it isimportant to acknowledge the drawbacksof an ageing population. For example, theincidence of degenerative neurologicaldiseases such as Alzheimer’s is on the in-crease. In light of rising public and privatepro capita expenditure on health in virtu-ally every country in the world, the ageingof the population clearly poses a majorchallenge for all healthcare systems.

The second presentation was given by KurtWagner from Vienna City Council. Mr. Wag-ner tackled the challenge of demograph-ic change head on and highlighted manyof the specific problems facing the Austri-an capital. Securing sufficient funds to pro-vide health services, a problem familiar tohospital managers, was another key partof his contribution.

Other presentations addressed a rangeof issues, including cooperation betweenproviders of nursing home care and thehospital sector, in other words, the transi-tion from illness to needing care. One con-tribution focused on how we should defineoptimum patient care. Does it mean pro-viding all possible aspects of care or onlythose which are needed? The medical chal-lenges arising from increased life ex-pectancy were also discussed.

Another presentation - Older Staff: Head -ache or Treasure Trove? – dealt with an im-portant topic which is often overlooked indebates on demographic trends. The issueof diversity was scrutinised in a presentationwhich used as an example the migrant com-

munity in Vienna, its health needs and thedemands it places on the health service. Un-fortunately, for reasons of space, it is notpossible to do justice to the various contri-butions by discussing them in detail.

Workshops and Summary

Several workshops were arranged to allowparticipants to respond to what they hadheard at the congress. Delegates were en-couraged to express their opinions, offerideas and make recommendations. Oneworkshop focused on Economics in Health-care, while a second took as its theme theissue of Care for the Elderly. Reports onthe conclusions reached at the workshopswere delivered in the plenary session andrevealed a wealth of creative and innova-tive proposals. While the congress may nothave found a panacea for all healthcareills, it produced many useful ideas. The col-lective knowledge of the health profes-sionals in attendance demonstrated thatthere is no shortage of good ideas in thehealth and hospital sectors. The problemin many cases, one which is not confinedto Austria, is the inability of policymakersand healthcare providers to translate ideasinto action.

(1) “50 Jahre Arbeitsgemeinschaft” is available inGerman only at www.argev-wien.at/show_2308.aspx (2) See Hospital 1/2008, pages 35 and 36: Hradsky,J. “The Austrian Association of Hospital Managers”(3) An overview of the Congresses is available in Ger-man only at www.argev-wien.at/show_2278.aspx

Author:

Regierungsrat Josef HRADSKYWorking Group of Health Managers and Karl Landstein Institute for HospitalOrganisation, ViennaE-mail: [email protected]: www.argev-wien.at and www.karl-landsteiner.at/institute/krankenhausmanagement.html

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06 (E)Hospital | Issue 1 - 2009

POPULATION GROWTH – A CHALLENGELatest News From the Association of Hospital Managers of Vienna





Green Paper on the European Workforce for Health

Last December, the European Commission adopted a greenpaper on the EU workforce for health. This marks the beginningof a consultation period which aims to identify common re-sponses to the many challenges facing the health workforce inEurope. A high quality health workforce is crucial for success-ful health systems. The health workforce plays an importantrole in the EU economy, accounting for about 10% of all jobs.In addition, 70% of EU healthcare budgets are allocated tosalaries and employment related issues.

The aim of the green paper is to increase the visibility of theseissues, to generate a clearer picture of the extent to which localand/or national health managers face the same challenges andto engage stakeholders in the debate so as to help those re-sponsible across Europe to address these problems effectively.

The results of the consultation will feed in to what the EU cando to support member states in tackling these challenges. http://ec.europa.eu/health/ph_systems/docs/workforce_gp_en.pdf

First EU Health Prize for Journalists

The European Commission has launched the first EU healthprize for journalists as part of the Europe for Patients campaign.The prize has a dual purpose: the recognition and promotionof high quality health journalism across Europe. It is hoped thatthe prize will stimulate and contribute to the debate on EU healthissues, specifically those initiatives related to the Europe forPatients campaign.

The Europe for Patients campaign was launched in September2008 by EU Health Commissioner Androulla Vassiliou to providea single entry-point to the often complex world of EU healthcarepolicies and actions. The Commissioner has emphasised the re-sponsibility journalists have in communicating EU health policiesto European citizens, especially concerning the Europe for Patientscampaign which focuses on issues that affect us all such as crossborder healthcare, patient safety and organ donation. She hopesthat this prize will have the desired effect and stimulate debate ona local, national and international level.

Articles published in print or on-line publications between 2 July2008, when the first Europe for Patients initiative was adopted, andthe closing date of 15 June 2009 will be considered. Journalists areinvited to submit their articles using the on-line entry form on theEurope for Patients website.

http://ec.europa.eu/health-eu/europe_for_patients/index_en.htm

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European Commission’s Communicationand Recommendation on Patient Safety

Each year in the EU between 8% and 12% of patients ad-mitted to hospitals suffer harm from the healthcare theyreceive, including from healthcare associated infections.Much of that harm is preventable. Therefore, last Decem-ber the European Commission adopted a communicationand a proposal for a Council recommendation with spe-cific actions that member states can take, either individ-ually, collectively or with the Commission, to improve thesafety of patients.

The Commission held a public consultation earlier last year,the results of which have informed the current proposal.This follows an earlier consultation on the specific threatto patient safety posed by healthcare associated infec-tions. Working groups representing member states andkey stakeholder groups, including health professionals andpatients, have also contributed to discussions.

The Commission has already taken individual initiatives inthe past, such as addressing certain aspects of patientsafety in community legislation, or fostering research andcollaboration on patient safety by community co-fund-ed projects. With this communication and the accompa-nying proposal for a Council recommendation, the Com-mission aims to put in place an integrated approach topatient safety.http://ec.europa.eu/health/ph_systems/patient_safety_en.htm

EU Crossborder Health Directive

During the month of December, EU health ministers metin Brussels in order to discuss the crossborder health di-rective. They focused their discussion on the first threechapters of the draft directive. While some progress hasbeen made since the tabling of the draft directive, somehealth ministers have shown restraint and have proven di-vided on its support. They reaffirmed their fears about aloss of national sovereignty over healthcare, while othersexpressed a wide range of views on the scope and imple-mentation of the directive. They reached general con-sensus on improving legal recourse for crossborder pa-tients, as well as expressing their preference for a provisionallowing "informed choices" and enhanced cooperationbetween countries.

The ministers at the Employment, Social Affairs, Healthand Consumer Affairs Council will discuss this reviseddraft, after the Parliament has issued its opinion, in Juneof this year.





the current EU initiatives in crossbor-der healthcare, quality and safety oforgan donations and transplantations,rare diseases, as well as patient safetyand the control of nosocomial infec-tions, with a focus on an ti microbial re-sistance. It also articulated great in-terest in the development of “thedefinition of financial sustainability andits objectives, and on the analysis ofthe resources available for healthcarefunding”, in an effort to be better pre-pared for the May 2009 high level con-ference. This conference is the perfectforum in which “to share experience andexchange information and best prac-tices concerning healthcare systemsand their financial sustainability.”

The Presidency has also expressed agreat interest in e-health and telemed-icine. It has asserted its disposition toincrease the quality of healthcarethrough the aid of telemedicine andstrengthening the interoperability ofinformation systems in the healthcaresector. It has also proclaimed that “inFebruary 2009, the topic of e-healthwill be discussed at a ministerial con-ference organised in coop eration withthe Commission,” with the aim of im-proving cooperation between EU mem-ber states in this sphere.

EHCI Rates the Netherlands as “Best Healthcare System in Europe”

In November, the 2008 editionof the annual Euro Health Con-sumer Index came out with itsfacts and figures for the year.This publication, which compris-es 34 indicators of quality, rankedthe Dutch healthcare system as“the best” in Europe.

The overall ranking was dividedinto six categories: e-health, pa-tient rights, patient information,waiting time for treatment, wait-ing time for pharmaceuticals,and the speed at which newdrugs are deployed.

The report went on to single outDenmark, Ireland, Czech Republicand Hungary for praise due totheir noteworthy improvementratings. Not all in the report waspositive however. It also gave adamning warning that standardsmay be falling, particularly interms of patient waiting times inmany member states.

N E W S M E M B R E R S> N E W S E U R O P E


Work Programme of the Czech Presidency (1 January – 30 June 2009)

As of 1 January the Czech Republic hastaken over the Presidency of the EUand has announced their “work-plan”for the upcoming months.

In the sphere of employment, theCzech Republic has announced that“worker mobility within the EU” is oneof their top priorities. They believe “re-strictions on the free movement ofworkers constitute a major barrier tothe development of the internal mar-ket, hampering full use of the real po-tential of the EU member states andthe EU as a whole”, thus promoting the“full liberalisation of the movement ofworkers within the EU and the simpli-fication and increase of professionaland geographic mobility of workers inthe labour market.” Along the samelines, the Presidency believes that a“practical implementation of the In-tegrated Guidelines for Growth andJobs and of the general principles offlexicurity” are needed to improve con-ditions within the EU in general.

Regarding the health sector, the Pres-idency has announced its support for



The biggest challenge facing the Czechgovernment during its European pres-idency over the next six months will be

to secure agreement on new legislation toupdate existing European working time rules.Prague, with the help of the European Com-mission, has just three months to end thestand off between national governments andthe European Parliament which emergedshortly before Christmas over the terms andconditions of the new rules.

If it succeeds, the new legislation could be im-plemented within two to three years. If it fails,the existing legislation will remain in place. Thiswould allow national authorities, 15 of whom al-ready do so, to continue using the opt out fromthe 48 hour maximum working week if they wish,

but would cause almost every country prob-lems with on call time for medical and emer-gency staff at their place of work.

The European Court of Justice (ECJ) has re-peatedly ruled that on call time should becounted as working time – an interpretationthat would cause huge costs for health serv-ices. Some have even predicted this couldmean hospitals in some countries beingclosed between midnight and 6am.

The Commission has investigated existingpractices throughout Europe and concludedthat all 27 EU members are breaking the ex-isting rules, as interpreted by the ECJ, in oneway or other. A raft of embarrassing court cas-es against national capitals is not expectedimmediately, but their prospect is definitely inthe wings.

The Czechs have wasted no time in trying tofind a way through the current deadlock. Theyorganised a meeting of senior national offi-cials in Prague in mid-January and followedthis up a week later with further informal min-isterial discussions. The stance being takenby most governments was clear, according toofficials close to the issue.

There is strong support among many gov-ernments to give health and emergency serv-ices flexibility by retaining the opt out indef-initely – a stance that sets member statesagainst the European Parliament which vot-ed in December to phase it out.

However, there are suggestions that a com-promise might be possible over the defini-

tion of on call time at the place of work. If so,this would need to bridge the governmentview that inactive time does not count to-wards the working week and the parliamen-tary position that all such time should be con-sidered as work.

As if reconciling these different views was notenough, any agreement must be reached andapproved by EU governments and MEPs bythe time of the last European Parliament ple-nary session at the beginning of May, beforethe European elections in June. If that dead-line is missed, the proposal for reforming theexisting legislation falls and the existing meas-ures remain in place.

Despite this high profile legislative challengethey face, the Czechs are looking to move thepublic health agenda forward on many fronts

in the coming months. In line with one of thewider political objectives of its presidency –advancing a Europe without borders – theywill address some of the obstacles in the wayof cross-border medical care.

They will also be taking up the Commission’sproposal to improve the quality and safety oforgan donations by setting Europe-wide stan-dards and encouraging greater cooperationbetween national health services so that sup-ply and demand are more aligned.

Currently, some 56,000 people in the 27 EUcountries are waiting for an organ transplantand a dozen are expected to die every daybecause of an absence of suitable donors.While donor numbers and transplants areincreasing across Europe, rates vary con-siderably from 34.6 donors per million peo-ple in Spain, to 13.8 in the UK and just 0.5 inRomania.

Another issue that the Czechs will be focusingon will be moves to tackle antibiotic resistance.As Dr Panova Stanislova, a director in the coun-try’s health ministry, told a Brussels conferencelast November, the country has a long tradi-tion of work in this area and the subject will beexamined at a conference on antimicrobial re-sistance and patient safety.

The digitalisation of healthcare services andthe development of e-health will also be onthe agenda with a two-day conference in mid-February, as will the financial sustainability ofhealthcare systems, which will be the subjectof a two-day conference in early May.

Finally, the Czech Presidency will be organis-ing early national reaction to the Commis-sion’s proposal towards the end of last yearto update pharmaceutical legislation. This isdesigned to boost innovation and researchand to make the industry more competitive,but at the same time contains the contro-versial suggestion that drug companies shouldbe able to give information on certain med-icines direct to patients.

CZECH EU PRESIDENCYBy Rory Watson

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11Issue 1 - 2009 | (E)Hospital

N E W S E U R O P E> E U A F F A I R S

Despite this high profile legislative challenge they face, the Czechs are looking to move the public health agenda forward on many fronts in the coming months.



The increase in demand forhealth services tends moreand more often to outstrip

the increase in supply. Ageingpopulations, in creasing incidenceof chronic diseases, and improve-ments in medical knowledge andtechnological equipment are themain demand drivers across theEU. The financial and real re -sources available for meeting thisincrease in de mand are limited. Asa result of this wors ening mis-match, the generic in ves tmentchallenge is to improve the per-formance and capa city of thesupply side in order to meet someof the growth in demand. TheEuropean eHealth IMPACT (2006,www.ehealth-impact.eu) and EHRIMPACT studies (2008 www.ehr-impact.eu) showed that effectivee-health solutions can substan-tially contribute to im provementsin quality, access and efficiencyof healthcare, thus in creasing thecapacity of the supply side.

How to Invest in E-Health?

The recently completed Financinge-Health Study (2008, www.finan cing-ehealth.eu) provided a genericguide for potential e-health in -vestors to support them in thedecision making process. The guide,addressing decision makers andmanagers, sheds light on, anddraws the connection to, the overall decision taking and chan gemanagement processes that arepart of e-health investment.

The main lesson regarding themodels to adopt is to integrate thee-health investment decisions intothe healthcare strategy of theorganisation. E-health can deliv-er, but it has to become part of the

general resource mix consideredin addressing healthcare needs.Then, e-health investments areconsidered alongside more con-ventional investments and theones with the best value for moneycan be selected. The financingmodel for the investment shouldonly be considered after the eco-no mic analysis is being performed.The approach is illustrated in thefigure below. Too often, invest-ments are driven by affordabilityconsiderations and not by a com-parison between investment andthe economic value of its impact.

The Process of Economicand Financing Decisions

Common difficulties in e-healthinvestments reflect the differ-ences between e-health and con-ventional ICT investment. E-health focuses on changes in theway healthcare is delivered, whichis a demanding endeavour. In e-health investment, ICT serves onlyas an enabler, not as an end. Inthis context, the main obstaclesto success include:

unrealistic timescales;underestimated risks;inherent procurement difficulties, and,a common misperception of the nature of most valuablebenefits from e-health.

Timescales for E-Health

Project management for some e-health projects focuses mainly ondeploying and managing theresources during the design,development and implementa-tion stages, and possibly the initialstages of operation. This time -

scale can be too short for sust -ain able e-health investment. Itmay fit an ICT project, but seldomprovides the time required for theactivities needed to realise netbenefits: typically, about four yearson average and at least eightyears for EHRs. The appropriatetimescales extend well beyond thebusiness and financial planning ofmost healthcare provider organ-isations and can present financ-ing challenges for e-health.

Instead, the e-health investmentlifecycle should be set by the timeneeded to realise the required netbenefit, the ultimate objective.This will enable the managementand productive utilisation of allthe reallocated resources, as partof change lifecycle.

Risks

Like all investments, as com-plexity and scale increase, so dothe scope, probabilities andcosts of risk. Plans for e-healthinvestment seldom evaluate thepotential of risk realistically. Theresult is no re cognition of risksas costs, no mi tigation and norespective fin an cial provision.This in turn leads to understatedcosts and overstated benefits,which is not a good foundation fore-health in vestment.

For example, engagement withusers and other stakeholders is ahigh risk activity. Where it is notsuccessful, the effect can inhibite-health activities for many years.Where it is successful, e-healthinvestors tend to apologise forthe extended timescales, under-stating the significant reductionin risk by pursuing effective col-

laboration and engagement, es pe- cially with healthcare professionals.

Procurement

Another concern is that there is stilla mismatch between supply anddemand for e-health systems andtools. Experts consulted in theFinancing eHealth Study reportedof repeated occasions in which ICTsuppliers were not in the position tosupply the solutions needed forbenefit realisation, leaving invest -ors with the task to develop ratherthan procure. At the same time,requirements are not always set ef -fectively by procurers, making thelives of ICT vendors more difficult.

The Value of Non-Financial Benefits From E-Health

The challenge is to ensure thatthe total investment matches anappropriate total economic ben-e fit. It is important to treat e-health investment in the sameway as other new investments inhealthcare, such as new drugs andsurgical techniques. It should notbe a means of saving money andimproving overall cash flow, but aninvestment in better healthcare.

Large proportions of economicbenefits from e-health are fromquality, including patient safety, andtime improvements. E-health isusually a net investment, with anegative financial return, so finan-cial benefits must be realistic in theirvalue and their timing. Sust ainablee-health investment re quires thatall decision takers and financialstakeholders are clear about thedistinction bet ween economic ben-efits and fin ancial savings.

E-HEALTH INVESTMENT

By Alexander Dobrev, Tom Jones and Karl A. Stroetmann

High Potential Opportunity and Managerial Challenge


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13

The task is to identify, define anddescribe all the benefits neededfrom better information for eachstrategic initiative. There are sever-al examples, such as inform pa tientsbetter, improve patient safety, im -prove timeliness, streamline healthcare, improve clinical effectivenessby sharing patient information withother healthcare profes sionalsthat form the multi disciplinaryteam providing patient care, andmodernise healthcare: all qualitygoals. Some citizens, such as thosein remote locations, may needimproved access to hospital andother specialist health services.Improving efficiency by saving timeand cutting waste may be a priority.

The Impact of E-Health on Hospital Management

The critical requirement for leaders,executives and e-health stake-holders is to be able to deal with e-health investment as an integrat-ed part of all healthcare investment.Finance executives and managershave a more specific role. First, theyneed to understand the value andimpact of e-health, so they canextend and develop financial plan-ning to deal with e-health invest-ment time scales. Second, theyneed to extend their financial man-agement skills to be able to devel-op ways to invest in better value.

This expands the principle of org -anisational change from healthcare professionals who use the e-health investment directly, to thewhole organisation. It is just as un -comfortable for executives as it isfor healthcare professionals. Ashealthcare professionals use newinformation to improve quality, ac -cess and efficiency, executives areconfronted with new clinical, work-ing, and information exchangepractices: they have a differentorganisation to run.

Conclusion

E-health is slowly becoming a musthave in modern healthcare. Expect -ations and resource constraints callfor a high potential response, ande-health seems to be part of it. This

seems to be com mon wisdom, butbegs the question why e-healthinvestments are not always suc-cessful in proving their potential.The answer is to some extent con-veyed in this article, which is basedon extensive research for the Euro -

pean Commission in the Fin ancingeHealth Study. More needs to beinvested in acquiring appropriateknowledge and experience with e-health in order to master the man-agerial challenges associated withrealising its potential.

Authors:Alexander Dobrev, Karl A. Stroetmann, Empirica, GermanyTom Jones, TanJent, UK

Email: [email protected]

Source: © TanJent/empirica 2006

Issue 1 - 2009 | (E)Hospital



E-health refers to the appli-cation of information andcommunication technolo-

gies to the healthcare sector.From the management of theelectronic patient or staff data,to the use of telesurveillance,telesurgery, teleexpertise, tele-consultations, to long distancelearning by personnel members,e-health manifests itself througha wide range of products andservices within the hospital con-text. But what about the legal im-plications of such applications?

e-Health applications are oftengoverned by regulations on theright to respect for private life andon the processing of personaldata. But in order to ensure thesound management of a hospi-tal there are many other condi-tions and regulations to be ad-hered to, depending on the angleand approach of analysis.

Information Management

Information management is keywhen it comes to the use of ICT.In this regard, it is necessary tohighlight that regulations con-cerning processing of personaldata are largely harmonised with-

in the EU. To summarise, theseregulations require to identify thepurposes pursued by the datacontroller - in this case, the hos-pital (medical or nursing man-agement, scientific research,healthcare quality control, reim-bursement of healthcare costs,etc.), the different actors involvedin the collection/management ofthe data (the data controller andthe processor, the data subject,the personal data protection of-ficial, etc.), as well as the rightsand responsibilities - awarded bylaw - in terms of general condi-tions of lawfulness, the data sub-ject’s rights (i.e. the patient or staffmembers), of notification, secu-rity, and confidentiality.

As well as the processing of per-sonal data, intellectual rights(rights of the author, copyrights,and trademarks) must not be for-gotten. An example of this wouldbe the creation and use of soft-ware and databases.

Equipment Management

Whether they are designed as"autonomous" (meaning througha wireless network of telecom-munications allowing easy com-

munication among practition-ers) or in interaction with otherpre-existing hospital equipment(such as a connection througha wireless system to a EEG de-vice), e-health products mustcomply with general regulationsfor products and equipment aswell as specific regulations formedical devices.

Healthcare Managementand the Free Delivery ofServices Within the EU

The use of ICT is likely to influ-ence the conditions in which hos-pital activities are exerted. Whenthe hospital offers remote serv-ices, questions are raised con-cerning conditions for the pro-motion and delivery of theseservices. Most notably in termsof information society services,of quality criteria for healthcarewebsites, of professional qualifi-cations for health practitioners,of unfair trade practices, of mis-leading publicity, of online con-tracts, of electronic signatures,and of the online promotion andselling of drugs. This also raisesquestions regarding conditionsfor creating electronic commu-nication networks in healthcare.

In this respect, discussions re-main underway on the usage ofbandwidth for telemedicine ap-plications within the frameworkof universal service.

Similarly, if the hospital uses serv-ices offered by external providers,a set of conditions must be de-veloped in order to appeal tothese providers. This is particu-larly relevant concerning therecognition of their professionalqualification if they do not fallwithin the same jurisdiction. In thisregard, it is necessary to re-member that, as a rule, within theEuropean Union, online medicalservices can be offered from anymember state and these servic-es are subject to the law of thestate of origin, except when re-ceiving states perceive them tobe duly justified special cases(such as cases that affect pub-lic health).

Hospital Liability

The question of liability for dam-ages caused by the use of ICT isa recurrent one, even if some un-derestimate it. Any hospital in-tending to use ICT in its day-to-dayperformances cannot dis regard this

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By Jean Herveg

(E)Hospital | Issue 1 - 2009

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ICT USAGEIN THE HOSPITAL ENVIRONMENTLaws and Regulations: Ensuring the Safe and Successful Implementation of e-Health



question. At European level, there are two legal in-struments that partially address this issue. Firstly,there is legislation on the processing of personaldata, which sanctions the right of the data subjectto hold the data controller liable for any illicit pro-cessing or of any action incompatible with the ap-plicable national law. Secondly, there is the legisla-tion on the liability for defective products.

As for the rest, it is necessary to interpret the law asit applies to each individual case, if need be accord-ing to private international law for international cas-es. What must be remembered is that there is a se-ries of legal instruments in place at European levelthat can prove to be useful in matters of jurisdiction,of applicable law (be they of contractual or non-contractual obligations), of serving, of recognitionand execution of judicial decisions.

Competition

The relationship between a hospital's activities andcompetition law gives rise to questions of particularsensitivity. Among these the primary concern is thevery idea of applying competition rules to the health-care sector. If competition laws are found to be ap-plicable, it is then necessary to look into questionsrelating to inter-hospital agreements, concertedpractices and abuses of dominant positions, with-out forgetting those related to state aid and inter-hospital mergers.

Conclusion

The legal aspects of e-health in hospitals are notlimited to matters of right to respect for private lifeor to regulations on the processing of personal data.They are also pertaining to equipment laws, laws re-garding services, as well to hospital liability laws andcompetition rules. A great portion of these rules andregulations are not specific to the hospital sector orto healthcare. It is not however, always possible toavoid the examination of their value when using ICTin a hospital concerned with the sound managementof its activities.

Author:Jean Herveg, Member of the bar of Brussels, Research Centre on IT and Law, Belgium www.crid.be

For more information, please contact:C. VAN DOSSELAERE, J. HERVEG, D. SILBER, P. WILSON, Legaland regulatory aspects of eHealth - Putting eHealth in its Eu-ropean Legal Context, Brussels European Commission, Direc-torate General « Information Society and Media », March 2008. (http://ec.europa.eu/information_society/activities/health/docs/studies/legally-ehealth-report.pdf)

15



Health requirements andthe demand for serviceshave seen substantial

changes in recent years. Increas -ed life expectancy has resultedin a greater prevalence of chron-ic pathologies. The WHO has clas- sified this situation as priority evenin developing countries. Currentmodels of patient care need tobe revised, with a greater empha -sis on patients taking a more ac-tive role in diagnostic and ther-apeutic pro cesses. Patients willneed to make substantial chan -ges to their life style, but thesebehavioural changes can only beachieved when the patient hasthe necessary information, acquir esnew skills and adopts a more pos-itive attitude to the problem.

Today we are faced with a grow-ing need for more health infor-mation from the population ingeneral whilst witnessing an ex-panding capacity of accessibili-ty to information thanks to new

forms of communication and in-formation technologies. Thismassive expansion has resultedin a proliferation of content thatat times can be of dubious qual-ity, which is not in the patient’sbest interest.

Determining the ForumContent

Content had to be selected andprioritised. This was achieved us-ing the following criteria:

The degree of prevalence of the illness;The existence and size of anexisting network of patientsthat can guarantee the spreadand impact of new and customised material;Degree of relevance and current interest of the materialproduced, both for specialistsin the field and affected patientsas well as originality of the material;

Quality and experience of thespecialist medical team that willprepare the material;How chronic the disease is; Level of interest in the chosensubject by health administrationbodies, andEffectiveness of therapeuticeducation in improving patient’squality of life.

Following this criteria, we com-pleted monographs on ischemiccardiopathy, diabetes, chronicobstructive lung illness, schizo-phrenia, breast cancer, depres-sion and factors of cardiovas-cular risk. Arthritis and arthrosis,obesity and bipolarity are alsoin production.

Authors are professionals fromhospitals, clinics and associatedhealth centres. The project hasbeen financed by the FundaciónBBVA, a non-profit organisation.Information combines the best sci-entific evidence available, profes-

sionals’ experience and individualpatients’ perspectives. It is avail-able in DVD format and can alsobe accessed via a web site (http://www.forumclinic.org) containing in-formation as well as videos.

The Portal

The portal (www.forumclinic.org)combines content of general in-terest in text and multimedia for-mat. The blog provides direct two-way interaction with the public.

Each illness section includes fourdistinct types of information:

• Text that summarises basic data on each illness;

• Recent news items related to the illness;

• Videos and 3D animations that explain biological mechanisms, among other aspects, and

• Professionally moderated discussion forums that form virtual communities. Forums

FORUMCLINIC

By I. Grau, J. Gene-Badia, E. Sanchez Freire, M. Bernardo and M. DeSemir

An Interactive Programme for Patients with Chronic Illnesses


forumclinic is a set of audiovisual material (DVDs and Website) in both Spanish andCatalan launched in January 2007. Its purpose: improving the quality of life of chron-ically ill patients. Based on the premise that by having a better understanding oftheir disease patients can become more autonomous, the project aims to en-courage patient involvement in the clinical decision making process hand in handwith the healthcare team.

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facilitate dynamic group interac-tion between professionals andpatients via direct intervention,via moderation following topicsraised by patients, and via the‘suggest a topic’ suggestion box.

Quality Criteria

We are enrolled as members andhave received the seal of approvalof the Health On the Net Foun-dation (http//www.hon.ch), andhave been recognised by theBarcelona Institute of Doctors of-ficial web site. These accredita-tions require adherence to the fol-lowing standards:

Transparency and honesty (site provider, aim and objec-tive of the site, site’s source of financing);Authority: sources of all information provided as wellas dates of publication; Privacy and data protection;Updated status of information;Responsibility, andAccessibility.

Some Statistics

Even without promotion, the au-dience of the website has grown.Currently we receive an averageof more than 2,000 different vis-itors every day, half of whom are

from South America (breast can-cer is the most visited site). Theforums represent around 24% ofweb visits.

Forum visitors have a participa-tion rate ranging from 1.15% to5.5%. 195,000 DVDs have beendistributed through Spanish HealthCentres and patient associations.

Conclusion

The growth rate of visits to thewebsite, as well as posts to the fo-

rums together with the high de-gree of penetration that the DVDhas achieved confirm the appro-priateness of the material.

forumclinic has proved to bea useful electronic tool for bidi-rectional communication be-tween healthcare profession -als and patients, as well as fordisseminating scientific knowl-edge to the public in general,dealing with both scientific find-ings and the emotional aspectsof health care.

Authors:I Grau

1, J Gene-Badia

2,3,

E Sánchez Freire4, M Bernardo1,2,5,6, M deSemir1

1 Hospital Clínic de Barcelona, 2 Universitat de Barcelona, 3 Consorci d’Atenció Primària de Salut de l’Eixample (CAPSE), 4 Fundació Clínic per a la Recerca Biomèdica (FCRB), 5 Institut d'Investigacions BiomèdiquesAugust Pi i Sunyer (IDIBAPS), 6 Centro de Investigación Biomédica en Red en el área de Salud Mental(CIBERSAM). Spain





Since the publication in1999 of arguably themost important call to

action for patient safety, the In-stitute of Medicine’s report ‘ToErr is Human’, we have learnt alot about how to reduce risk inhealthcare and how to improvepatient safety. Technology clear-ly has an important role to playbut we know that it can also bringincreased risks which every hos-pital board member should beaware of.

Research has shown that thecontext in which we work affectsour behaviour and our chanceof making mistakes. For exam-ple long hours and tiredness in-creases our chances of slips andlapses; insufficient staff or poor-ly designed equipment increas-es the likelihood of us takingshort cuts and committing vio-lations; a lack of communica-tion and teamwork amongst col-leagues and poor trainingincreases the likelihood of knowl-edge based errors. Many ofthese latent, error producingconditions are organisationalfactors, often the result of man-agement decisions taken to sat-isfy other priorities and needs,such as meeting externally im-posed targets or balancing thefinances.

Using Technology to Reduce Risks in Healtcare

Computerised decision supportsystems (CDSS) have grown in

use in the last ten years, drivenby clinicians suffering from in-formation overload whilst beingpressurised to make accurate,cost effective, evidence basedclinical decisions. These systemsprovide access to a wealth of ac-cessible information removingover reliance on memory; theyuse the power of the technolo-gy to analyse tests and comparethe results to millions of storedimages and evidence; and theyaccurately perform complex cal-culations taking into considera-tion multiple patient factors.

Once a clinical decision is madeCDSS’s can help with ongoingtreatment. For example, elec-tronic prescribing systems takethe vagaries of the pen out ofprescribing. They can ensure thatblood tests are ordered when re-quired for certain high risk drugs.Alerts are built in to laboratorysystems highlighting abnormalvalues of test results. Reminderscan pop up to prompt a review,for example a re-assessmentof a patients risk factors for ve-nous thrombo-embolism (VTE).

Electronic patient records en-able fast access to important in-formation at the point of clinicaldecisions being made, where verthe patient is.

Technology, People and Patient Safety

When considering e-health ap-plications and patient safety it

is important to recognise thatwe have mixed relationships withtechnology. Some of us feel atease using the latest gadget,others haven’t mastered themobile phone and feel veryuncomfortable anywhere neara computer. The way we see,feel, understand and trusttechnology affects how we useit and this in turn affects pa-tient safety.

The rapid development of tech-nology makes it hard to keep up.The latest version always seemsbetter than the one you boughtlast week and there are constanttemptations to upgrade and im-prove. But this means multiplesystems can be in use in onehospital, all of different ages andpotentially not able to commu-nicate with each other very eas-ily. This increases the risk of staffnot being familiar with the tech-nology and not trained in its use.It also increases the risk of soft-ware related problems and theassociated costs to sort themout. For managers it brings prob-lems of not knowing who is mostup to date and best able to ad-vise the organisation on newtechnology.

Reporting and LearningAbout Adverse Events

It is vital in any organisation wish-ing to improve patient safety thatstaff report when things gowrong, or when there is a nearmiss. In any complex software

there can be a hundred millionlines of code and inevitably thiswill contain errors, making it dif-ficult to find the source of aproblem. Automatic error re-porting systems are built in tosome software, but not all, soother ways of capturing this in-formation becomes essential.

Even if problems are reported, ifit relates to the software it is of-ten very difficult to repeat whathappened and find the rootcause. The vendors of e-healthapplications often can’t find theroot cause of a problem becausethey have assembled the systemfrom components manufacturedby different companies – so eventhey are uncertain about how thesystem works as a whole .

Design of the Processes to Use E-health Applications

In improving patient safety it isimportant to recognise that hu-man behaviour is a function of thesystem in which people work. Forexample emailing pathology testresults to doctors may appear onthe surface to be very efficientbut if they are too busy to look attheir emails more than once a daythen this new system will guaran-tee that a patient’s abnormal testresults will not be acted upon im-mediately. If there is only onecomputer on each ward and doc-tors are queuing up to use it, thencomputerised decision supportsystems will not be used. Thereare many techniques to help

PATIENT SAFETY AND E-HEALTHBy Susan Burnett

18

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those implementing new technology to con-sider the processes and the potential risksthat may arise. Failure modes and effectsanalysis is one such technique that is in-creasingly being used in healthcare. For ex-ample in one unit they had overlooked theneed to ensure that the computer in the car-diac unit was always plugged into a socketpowered by the hospital’s generator in caseof a power failure. If the computer screenshowing where the probe was inside the pa-tient’s artery had gone blank in the middle ofa procedure the outcome doesn’t bear think-ing about.

It is often faults in the design of the process-es that create the conditions for staff to vi-olate the rules and take short cuts. Leav-ing a computer logged in on a ward for allto use because it takes too long to keeplogging off and on, sets up security prob-lems and the possibility of one doctor read-ing records for the wrong patient. In oneunit the staff took to carrying high risk drugsaround in their pockets because of prob-lems with the computerised pharmacy sys-tem. This highlights the importance of care-fully designing and thinking through theprocess for using technology in healthcare,not only during installation but on a regu-lar basis thereafter as other parts of thesystem change and develop.

Design of the Technology

With the increasing movement of profes-sionals between hospitals and betweencountries the issue of familiarity with thetechnology in use in healthcare becomesimportant.

Hardware

We know that not being familiar with the tech-nology can cause errors yet we still do nothave standardisation of even the basic equip-ment. In one study by the National PatientSafety Agency in the UK over 60 differenttypes of infusion device were found to be inuse in one hospital. Starting in the top left,some of the keypads counted down from ‘9’,others counted up from ‘0’ with the potentialfor patients to be given massive overdoses.In a truly safe hospital system, all technologywould have a common user interface allow-ing staff to walk in to any ward or clinic and beable to safely use any device or technology.

Software

Even if the technology is well designed, the soft-ware can let the operator down. For exampledrop-down boxes in electronic prescribing sys-tems having drugs in alphabetic order puttinghighly toxic drugs with similar names next to themost commonly prescribed antibiotics, with in-evitable consequences. Electronic prescribingsystems have alerts built in to them to notify adoctor of a potentially toxic drug or combina-tion of drugs but these systems often have waysof turning the alerts off or ignoring them byquickly pressing the return button. If alerts reg-ularly appear they can become irritating andover time their impact lessens to the point wherethey are completely ignored.

Technology and the Operator

Skills and knowledge can be acquired in us-ing the technology but the human conditionbrings other factors into play that need con-sidering in the context of patient safety.

Trusting the technology

In two tragic cases in the UK patients wereoverdosed when receiving radiotherapy treat-ment. Despite the procedures for checkingdoses, the staff had begun to trust each oth-er and the machine and their levels of vigi-lance had reduced. Lisanne Bainbridge (1987)set out some of the principle ‘ironies of au-tomation’ and here we find one: the fact thatvigilance and monitoring, checking the per-formance of a machine over long periods oftime is notoriously difficult for humans to per-form but we often rely on it.

Applying what we know from other systems

When the computer at home freezes, afterwe have made our usual attempts to sort outthe problem, we press the re-boot button,never quite understanding why it froze in thefirst place. Applying this approach to e-healthapplications can have much more seriousconsequences, losing valuable patient dataor at worst re-setting carefully calibrated pa-tient monitoring systems.

Readily available and non-judgemental sup-port for people using complex technology iscostly but vital with all applications in the hos-pital. Here we find another of Lisanne Bain-bridge’s (1987) ‘ironies of automation’: we



leave the operator to carry outthe tasks that the designercouldn’t find a way to automate– such as the operator being leftto recover a system breakdown.If the new technology has beenintroduced with the requirementto save money then often thereis a downgrading of the skills ofthe people operating the sys-tem and with fewer clinical staffoperating e-health technolo-gies, risks will inevitably increase.

Mental workload of the operator

Physician job satisfaction wasmeasured in one study oftelemedicine assessing in par-ticular mental workload. The re-search into the telemedicinesystem found that the mentalworkload scores were high forthe doctors and commensuratewith those of air traffic con-trollers. This area requires muchmore attention as the technol-ogy becomes more complex.

Security and Backup

The loss of identifiable data heldon computers is not uncommon.In November 2007 the govern-ment lost 25 million records giv-ing details of names, addressesand bank accounts for peopleclaiming child benefit . Despitesystems and procedures andpolicies to prevent such loss, therules are violated to save timeand to help doctors with patientcare – in one hospital I workedin, a doctor regularly saved ona USB key the records of the pa-tients he was due to see the nextday in outpatients, reading themat home in the evening. I foundout when a member of his son’scomputer hacking ‘club’ ranganonymously to say he hadgained access to the records!

E-health applications are nowbeing designed to allow remote

access by healthcare staff andalso by patients via the internet,making the systems increasinglyat risk from viruses and illegalaccess . Good practice in IT dic-tates that hospitals have sys-tems in place for regular se curitytesting, reporting vuln er abilities;that vendors should take stepsto ‘harden’ their systems whenimplemented, for example en-suring that applications thatmight increase vulnerability areswitched off and services on theinternet are disabled, pop-upsand cookies blocked for exam-ple, but even these can be vio-lated, especially if it means timeconsuming log-on proceduresor slow functionality.

What About the Patient?

Studies of patient satisfactionwith telemedicine are revealing– some patients are concernedabout telemedicine meaning re-duced social interaction with thedoctor, feeling ‘distanced’ fromthe hospital; some are unhappyabout having photographs tak-en and transmitted electroni-cally (just look at what appearson YouTube!). Yet other studieshave found patients prefer tocommunicate over the internet,avoiding travel to hospital andavoiding face to face contact.

What we don’t know is how all thisaffects patient safety – does thefeeling of being distant from thedoctor mean that patients aremore or less likely to comply withtheir treatment? Are patientsmore or less likely to reveal per-sonal details required for a di-agnosis over a telemedicine linkif they are not sure who is watch-ing? What about cultural differ-ences? What about language?More research is needed here.

What we do know is that patientsand their families will interactwith health technology in hos-

pitals and at home. For exam-ple they will turn off irritatingalarms; change dosages; and in-terpret and act on warnings.Family members will be asked tohelp or may play with the ma-chine to see how it works. Againthis is an unexplored area interms of patient safety.

Quality Assurance –is the Technology an Improvement?

How accurate are the decisionsbeing taken using the CDSS? Arethe prompts and reminders be-ing acted upon? Are appropri-ate tests and drugs being or-dered? If the CDSS relies oninformation from other systemswithin the hospital, such as thelaboratories and pharmacy, whatreliability checks are performedto ensure these systems alwayscommunicate? What systemsare in place to ensure that overtime the knowledge base is keptup to date and that any newknowledge is checked and ver-ified and agrees with local andnational guidelines? And of mostimportance, how is patient mor-bidity and mortality affected bythe CDSS – has the changebeen an improvement for pa-tient care?

Management, Governanceand Accountability

In the book ‘Management Mis-takes in Healthcare’ a casestudy is presented relating tothe purchase and installation ofa new computer system inHeartland Healthcare System.The study sets out the man-agement failures that can oc-cur with the introduction of newtechnology ranging from re-cruiting people without the req-uisite IT skills and knowledge; ill-defined roles of IT contractors;an absence of goals and meas-ures of success; the absence of

accountability; non-adherenceto purchasing protocols; and afailure to prevent the ‘intra-staff’ warfare that subsequent-ly developed. Any one of thefailures listed would cause prob-lems with the introduction ofnew technology and could in-troduce the potential for sys-tems not to be set up safely.

Patient safety needs to be writlarge throughout the informa-tion technology strategy of anyhealthcare organisation andneeds to be central to the run-ning of all systems that inter-act with the technology andwith patient care. For examplein the human resource depart-ment issues arise such as staffinglevels and skills mix required touse the new systems; policiesabout the use of temporary staff,who may not be suitably trainedto use the applications; also theongoing training and accredita-tion for both new and existingstaff in the use of the technolo-gy. Many organisations have in-troduced new clauses in staffcontracts concerning the mis-use of IT for example.

E-health has the potential toenable significant improvementsin patient safety, it also bringswith it new risks. Hospital boardsneed to have an understandingof these risks, an understandingof the theory of human errorand systems thinking and en-sure they have the requisitemanagement systems in placeto deal with them.

Author:Susan Burnett, Programme Lead, Organisation and Management Group, Centre for Patient Safety and Service Quality, Imperial College, London, United Kingdom

Email: [email protected] www.cpssq.org


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In many European countries,health service managers arefacing increasing problems

of staff attraction and reten-tion. Especially in the nursinghealth workforce, turnoverrates are high, vacancies re-main open and the resultingstaff deficits lead to increasedworkload, burnout and reducestaff commitment.

During the last decade, severalEuropean countries took policymeasures to increase the inflowin the paramedical professionsand the retention of existingcadres, including the creationof new cadres of health workers,the recruitment of nurses fromother countries, better remu-neration schemes, and the in-troduction of more flexible work-ing conditions. Far less has beenwritten on how health servicemanagers can develop practicesto attract and retain healthworkers that go beyond offer-ing better financial incentivepackages or recruiting healthworkers from the South.

Several interesting alternativesto deal with staff shortageshave been developed else-

where. First, when major short-ages of nurses occurred athospital level all over the USduring the 1980s, some hospi-tals were found to attract andretain professional nurses [1].Second, high commitment management is a promising streamin the human resource man-agement literature.

This paper describes the keyprinciples of magnet hospitalsand draws lessons from highcommitment management thatcould be useful in the current

hospital staff crisis. In essence,we’ll argue that investment inrelations and in effective sup-port to health workers may payoff sooner than later.

Principles of Magnet Hospitals

During the 1980s crisis, magnethospitals stood out in the UShospital landscape because theyhad a low staff turnover and lowvacancy rates despite their lo-cation in areas with high com-petition for staff.

Nurses working within them con-sidered magnet hospitals asgood places to practise nursingaccording to their professionalnorms. Magnet hospitals werefound to share leadership, pro-fessional and organisational at-tributes. In other words, top man-agement created space andopportunities for mid-level(nursing) managers to devel-op responsive managementpractices that were appreciat-ed by nurses.

Table 1 summarises these attributes:

By Bruno Marchal

What Can We Learn From Magnet Hospitals?

FALLING NUMBERS OF HEALTH WORKERS:FACING THE CRISIS

Issue 1 - 2009 | (E)Hospital 21

H U M A N R E S O U R C E S

Magnet hospital nurse leaders (leadership attributes)

• visionary leaders, planning for the future• creating an organisational culture that enhances staff satisfaction and fosters professional growth• maintaining a high visibility: open communication, responsive to staff concerns and interests• supportive towards their own staff: (1) supporting staff involvement in decision making and

control of patient care issues; (2) supporting staff development & Continued Medical Education

Clinical nursing practice (professional attributes)

• adequate autonomy within clinical practice, allowing nurses to establish and maintain therapeutic nurse-patient relationships

• collaborative nurse-physician relationships • team autonomy: control over work

Organisational/management attributes

• participative management style including nurse managers in hospital-wide decision making

Table 1




Underlying Mechanismsof the Magnet HospitalApproach

The key principles underlyingmagnet hospital managementinclude:

(1) facilitating professional autonomy for nurses,

(2) participation in decision-making, and

(3) systematic communication [2].

Through such managementpractices, the professional nur s- ing practice is explicitly or impli c-itly valued and respected, andnurses are being empowered.

Magnet hospital managementcan, indeed, be considered asempowering nurses [3]. Man-agers give the nursing staff themeans, information and supportto optimally carry out their pro-fessional duties. Further studieslinked empowerment to increas edtrust in management and tocommitment to the organisa-tion and its mission of care [4].

Lessons From High Commitment Management

Management practices that areleading to high commitment ofemployees have been receivingquite some attention in HRM lit-

erature for a few years. Suchpractices have been shown tolead to better organisationalperformance, reduced stress andhigher productivity [5].

In essence, high commitmentmanagement consists of apply-ing complementary bundles ofHRM practices. Pfeffer identified7 key elements:

Selective hiring,Employment security,Comparatively high compensation contingent onorganisational performance,Instituting training and development,Self-managed teams and decentralisation,Reduction of status differences, and Information sharing [6].

The main message from the cur-rent literature, however, seemsto be that the exact composi-tion of the bundles is less im-portant than its internal coher-ence and external fit. Effectivebundles include practices thatare congruent (i.e. not cancellingout each other) and fitting wellwith the tasks the organisationis carrying out.

In American magnet hospitals,the hospital management teamswere able to find such bundles.

Involving staff nurses on hospital-wide crosscutting task forcesand committees, delegation ofresponsibilities and providingopportunities for further pro-fessional development are allstrategies that create respon-sibility and challenge. These inturn increase feelings of respectand recognition among nurses,which contributes to their pos-itive commitment towards thehospital and its mission. This ul-timately contributed to in-creased attraction and reten-tion in such hospitals.

Conclusion

The principles underlying mag-net hospital management can beassumed to be important for anyprofessional nurse, and as such,this approach seems prom ising.In practice, however, manage-ment approaches that focus onhuman relationships on the workfloor can be expensive in termsof time and management ca-pacity. Support to mid-level nurs-ing managers is of key impor-tance, and they should be giventhe opportunity to invest heavi-

ly in open communication, meet-ings and on-the-floor presence.

Second, the issue of staff com-mitment needs to be better un-derstood. What would staff ex-pect from management in returnfor their commitment to the or-ganisation? Salary buys indeedtime of employees, but otherpractices ensure their motiva-tion and commitment. Hospitalmanagers will need to find outwhat their nurses appreciatemost and consequently adapttheir management practices.Facing shortages and limitedpossibilities to further increaseremuneration, managers needto tap other sources of motiva-tion and commitment. Bothmagnet hospitals and the highcommitment management lit-erature offer interesting options.

Authors:Bruno Marchal, MD, MPH, ResearchFellow, Department of Public Health,Institute of Tropical Medicine,Antwerp, Belgium

Email: [email protected] references please contact: [email protected]


Magnet status is an award given by theAmerican Nurses’ Credentialing Center (ANCC),an affiliate of the American Nurses Asso -ciation, to hospitals that satisfy a set of crite-ria designed to measure the strength andquality of their nursing. A Magnet hospital isstated to be one where nursing delivers excel-lent patient outcomes, where nurses have ahigh level of job satisfaction, and where thereis a low staff nurse turnover rate and appro-priate grievance resolution. Magnet status isalso said to indicate nursing involvement indata collection and decision-making inpatient care delivery.

The original Magnet™ research study from 1983first identified 14 characteristics that differen-tiated organisations that were best able torecruit and retain nurses during the nursingshortages of the 1970s and 1980s. These char-acteristics became the ANCC Forces ofMagnetism that provide the conceptual frame-work for the Magnet appraisal process.

The 14 Forces of Magnetism are Quality ofNursing Leadership, Organisational Structure,Management Style, Personnel Policies andProgrammes, Quality of Care, Quality Improv -ement, Consultation and Resources, Auto -

nomy, Community and the Healthcare Orga -nisation, Nurses as Teachers, Image of Nursing,Interdisciplinary Relationships and ProfessionalDevelopment.

The idea is that Magnet nursing leaders valuestaff nurses, involve them in shaping research-based nursing practice, and encourage andreward them for advancing in nursing practice.Magnet hospitals are supposed to have opencommunication between nurses and othermembers of the healthcare team, and an ap -propriate personnel mix to attain the bestpatient outcomes and staff work environment.

What is Magnet status?

Involving staff nurses on crosscutting task forces,delegation of responsibilities and providing opportunities for professional development arestrategies that create responsibility and challenge.





For many reasons, it oftenmakes greater sense tohave certain hospital

functions performed external-ly rather than leaving thesetasks to the hospital itself. Suchreasons include greater flexi-bility, the ability to draw uponprofessional know-how, the ef-fects of synergies or coopera-tions, or the adoption of dif-ferent compensation systems.Furthermore, departments re-quiring expensive machinery,such as laboratories or radiol-ogy, are only able to functioncost-effectively if a partial am-bulatory utilisation is also pos-sible. Moreover, outsourcingplans are also driven by a trendtowards small entities that fo-cus on their core activities.Supplementary activities aremerely binding resources thatare desperately needed for thehospital’s core business: med-ical care and treatment.

General Remarks

No standard solution exists un-der German employment andlabour law with respect to theoutsourcing of measures. Thespecific circumstances of thehospital, the goal of outsourc-ing services or certain parts ofthe business, as well as the typeof the division affected, all leadto a broad range of possibilitiesfor the appropriate course of ac-

tion, e.g. the outsourcing of suchservices to an external serviceprovider, to a newly foundedcompany owned by the hospi-tal, or to a joint venture betweenthe external service provider andthe hospital.

Regardless of the chosen method,the outsourcing of services orparts of a business will in anycase raise several employmentand labour law related questions,including matters concerningthe transfer of business and par-ticipation rights of employeerepresentative bodies, i.e. theWorks Council (Betriebsrat) orStaff Council (Personalrat).

Transfer of Business

The mere outsourcing of func-tions will not necessarily lead towhat is legally known as a trans-fer of business (Betriebsüber-gang). However, in many cas-es the hospital will also transfermaterial assets, such as build-ings or machinery, and parts ofthe work force.

1. Definition

A transfer of business requiresthe transfer of a (complete)business unit to a new owner.The new owner must acquire aneconomic business unit thatmaintains its identity after thetransfer. The workforce and the

assets of a business unit, whichshare the common purpose ofperforming an economic activ-ity, determine the identity of abusiness unit. The German Fed-eral Labour Court (Bundesar-beitsgericht) considers severalaspects to be relevant in de-termining whether a completebusiness unit has been trans-ferred, and whether such a unithas maintained its identity.These factors include a trans-fer of the most material assets(both tangible and intangible);the continuation of the work or-ganisation; the similarity of workperformed at the business be-fore and after the transfer; atransfer of the main workforce;the type of industry concerned;and the period of time for whichthe operation of the businesshas ceased (if applicable).

Whether outsourcing servicesor parts of a business constitutesa transfer of business can only

be determined by a compre-hensive evaluation of the dealand the state of the target’sbusiness. This was confirmed ina ruling by the European Courtof Justice. The Court lately heldthat taking over a hospital cafe-teria without taking over anypersonnel nevertheless led to atransfer of business, since thecompany acquiring the cafete-ria also acquired the right towork with the heavy and expen-sive kitchen equipment.

Hence, under certain circum-stances, even mere successionsin function may result in a trans-fer of business. Furthermore,supplementary activities of hos-pitals (such as laundry servicesor security operations) dependheavily on the personnel andless so on the assets. Conse-quently, the taking over of ac-tivities and parts of the work-force may also lead to a transferof business.



By Thilo Ullrich

Impact of Employment and Labour Law

OUTSOURCING IN HOSPITALS

The European Court of Justice lately held that taking over a hospital cafeteriawithout taking over any personnel nevertheless led to a transfer of business, since the company acquiringthe cafeteria also acquired the right towork with the kitchen equipment.



2. Legal Consequences

If a transfer of business has oc-curred, the employment con-tracts of all employees con-nected to the business unit willbe transferred to the new own-er by operation of law. Provisionsof collective bargaining agree-ments with works councils andunions may be incorporated intoindividual employment con-tracts. Furthermore, the em-ployment contracts may not beterminated for reasons of thetransfer within one year of it tak-ing place.

Moreover, all employees affect-ed must be informed about thetransfer of business in writing.Each employee can object tothe transfer of the employmentcontract in writing within onemonth of receiving the notifica-tion letter. The employees’ rightto object will expire after onemonth only if the informationprovided was complete and ac-curate. If, however, the lettercontained incomplete or inac-curate information, the em-ployees’ right to object wouldnot lapse. The German FederalLabour Court has recently tight-ened the requirements for suchnotification letters.

Participation Rights of Works Council/Staff Council

Outsourcing may also triggerparticipation rights of the workscouncil or staff council, rangingfrom information rights throughto co-determination rights.Whether a staff council or aworks council exists depends onthe form of organisation. Staffcouncils are established in hos-pitals belonging to the public (i.e.state) administration, whereasworks councils are formed inhospitals that are organised ina private legal entity, e.g. a com-pany with limited liability (GmbH).

While such employee represen-tative bodies may not preventan outsourcing measure, theymay delay it considerably.

1. Staff Council

The participation rights of staffcouncils differ considerablyfrom federal state to federalstate, and may range from ex-tensive co-determination rightsto the mere hearing of the staffcouncil’s opinion. Where a co-determination right does exist,the administrative body mayonly initiate outsourcing meas-ures if the staff council hasagreed to the outsourcing pro-posal. In case the staff councildoes not agree, an arbitrationcom mittee is formed with a viewto negotiating the outsourcingmeasure.

But even in federal states thatgrant such co-determinationrights, it is the highest adminis-trative body that has the final sayon the outsourcing proposal,since the decision of the arbitra-tion committee is not binding.However, the co - de term inationprocedure may be both time-consuming and costly.

In certain federal states, the staffcouncil merely has to be in-formed (albeit thoroughly andin good time) about the out-sourcing plans and is entitled tobe heard by the administrativebody, including for negotiationsregarding the proposed meas-ures. If no agreement can bereached, the decision on theproposed measure is taken bythe administrative body next upin the hierarchy.

In addition, the staff council mayalso have co-determinationrights where the outsourcingplan requires the transfer or del-egation of employees within thehospital or to the external serv-ice provider (or joint venture).

2. Works Council

In private legal entities, the hos-pital may have to negotiate aconciliation of interests (Inter-essenausgleich) and a socialcompensation plan (Sozialplan)in the event that the outsourc-ing leads to a change of busi-ness (Betriebsänderung) in ac-cordance with Section 111 of theGerman Works Constitution Act(Betriebsverfassungsgesetz). Asa general rule, it is unlikely thatthe outsourcing of mere sup-plementary activities, such aslaundry services, will lead to achange of business, since theexternal procurement of minorservices has no general impacton the business as a whole.

By contrast, the outsourcing ofprimary functions, such as lab-oratory, radiology or nursingservices, is highly likely to resultin a change of business, there-by establishing co-determina-tion rights in favour of the workscouncil. In such case, if the hos-pital attempts to outsource measures without first negotiating withthe works council, the latter maybe entitled to seek an interim in-junction against the measures,and affected employees mayhave compensation claims.

In case the hospital manage-ment is unable to reach anagreement with the works coun-cil, an arbitration board will issue

a binding decision on the so-cial compensation plan. Theboard may not, however, de-cide on the outsourcing itself,but may only determine whetherthe management has taken allnecessary steps to find an am-icable solution. Thus, while theworks council may delay theprocess, ultimately it will notbe able to prevent an out-sourcing measure.

Conclusion

Outsourcing may lead to a mul-titude of employment andlabour law related problems. Inorder to establish what rights willbe afforded to the individual em-ployee, it is essential to deter-mine whether the proposal willresult in a transfer of business.

Furthermore, considerationmust also be given to the rightsof a works council or staff coun-cil, so as to prevent time-con-suming delays as well as cost-intensive claims. The careful andthorough legal preparation ofoutsourcing plans can there-fore prevent many problemsand, ultimately, save both timeand money.

Author:Thilo Ullrich, Attorney and certifiedlawyer for employment law (Fachan-walt für Arbeitsrecht), Berlin, Germany



All employees affected must be informed about the transfer of business in writing. Each employeecan object to the transfer of the employment contract in writing within one month of receivingthe notification letter.



The care of severe patientshas important physical andpsychological implications

for nursing staff. Also, the insti-tute’s location in the inner-ringsuburbs of Paris, its Ile de Franceenvironment and its access diffi-culties have made us consider theimprovement of working condi-tions for several years now.

The care management, in agree-ment with the general manage-ment and the department ofhuman resources, offered staffthe possibility to switch fromworking 8 hour shifts to 12 hourshifts. Being aware of the de -rogatory nature of this timetable,the switch over to 12h was doneon a voluntary basis, with anevaluation after 3 and 6 monthsin order to find a win-win solu-tion. The renewal process in theunit’s workforce with a decreasein the average age also favouredthis request of the unit staff. Ourwish to modify the working hourshad to take into considerationthe economic situation andcould not envisage an increasein workforce.

Methodology

The implementation of this newtimetabling model was achie vedin several stages:

An analysis of the Ile deFrance and institutional context by nursing staff, medical staff and humanresources. The assured commitment of these groups to the project was also important;Collaboration and proposition of the feasibilitystudy concerning the switchto 12 hours with the nursingstaff of the unit;The analysis of the organisation of care and the handling of patients withthe staff, the unit’s doctor, the nursing manager and the manager in charge,The analysis of the roles of registered nurses and auxiliary nurses by anergonomist bringing to lightorganisational problems. This was then shared with the team and organisational

targets set for the new context;The development of anacceptable scenario for each type of patient treated in the unit and the calculation of direct care workload with the headnurse. The goal of this was to reassure staff of the feasibility of the switch to 12hours in terms of care timeas compared with the currentworkforce;The adaptation of premisesand material for the neworganisation;The development of theframework for the schedule;Development of a completedossier of opportunities and organisation and presentation of this dossier to the administrative andunion (works council) authorities;Development of criteria forthe evaluation of the opera-tion’s success;Implementation and followup by the manager in charge, and Evaluation after 3 and 6months of implementation.

Conclusions

We now have 6 months hindsightsince the switch to 12 hour shiftsfor the registered nurses of theTarn unit. The long process (a -round one year) that we took toimplement the modification ofhours has permitted a betterunderstanding of the issues atstake and a newfound respect forthe different professions con-tributing to care. We had a verypositive response from patientswho knew “their” nurse for the day(sector of care) and at the mostfor the 2 following days.

The working atmosphere in theunit changed: different specialitiesrealised their organisational im -pact on each other and their inter- dependence. Six months into theswitch to 12 hours, we obs erved a40% decrease in abs enteeism dueto ill health. We also reclaimedhours dedicated to permanenttraining. Transfer re quests havealso stabilised.

Our demand for replacements for12 hour shifts (when necessary)are easier filled by temporaryreplacement registered nurses.Finally, the unit staff have ex pr -essed a real satisfaction con-cerning the improvement of theirworking environment.

Authors:Anne-Marie Teller, Directeur des SoinsPascale Witz, Coordonateur des Soinsen Chirurgie, Institut de CancérologieGustave Roussy, Villejuif, France




MODIFICATION OF WORKING HOURS OF NURSING STAFF IN ONCOLOGICAL SURGERY

Patient and Staff Satisfaction

The Gustav Roussy Institute, the first European centre of cancerol-ogy, is situated in the south of Paris, in the Villejuif district. Its fourhundred beds are divided between different sectors of medicine:paediatrics, general and cervico facial surgery. The “Tarn” unit,affected by the time table change, is situated in general surgery. Thissector of twenty-six beds caters for the “difficult” patients in gynae-cology and sarcoma.

By Anne-Marie Teller and Pascale Witz





Those responsible for run-ning a department repeat-edly come up against the

limits of practicability on many levels.Fixed-term projects can often bevery helpful here - they allow peo-ple to familiarise themselves witha new situation and examine towhat extent things have improved(or not). In this sense not onlyshould strengths be reinforced,but above all, weaknesses shouldbe given all the support they needto become strengths.

Also, the fact should not beoverlooked that a department,as “part” of a whole, must act inthe spirit of the whole and alsoreceive instructions in this spirit.The balance between this “re-cipient situation” and indepen d -ence in organising and im ple - menting the tasks on behalf ofthe people entrusted to us is oneof the key elements of depart-ment management.

Current developments in the healthsector show a trend towards:

Shorter stays in acute hospitals;An increase in age-specificillnesses (dementia etc.);More multimorbid patients inacute hospitals;An increase in chronic diseases

and the need for care, andA demographic shift in our society.

These changes can also be feltin the departments. The poten-tials of the organisation de-partment therefore need to beutilised and developed. Howev-er, effective management anda “learning” organisation arealso required.

Nurse and Doctor Cooperation

In the field of dual managementat department level (doctor andnurse), the significance of theprofitability dimension in man-agement is on the rise, as are“soft skills” such as social com-petence and conflict resolution.Nothing new there, but the op-timal cooperation of medicalprofessional groups, especiallybetween nurses and doctors, isindispensable. Working process-es must be coordinated andevaluated on a regular basis. Atthe same time there should beno “taboo subjects”, potentialsources of danger or actual mis-takes, and the “courage to ad-mit when you don’t know some-thing”, must be highlighted ascentral themes.

Guidelines

In Vienna’s hospitals, process,structures and framework guide -lines have been recently imple-mented to effectively carry outshared activities between med-icine and nursing. These guide-lines are based on the resultsof the project “Improving thequality of training of traineedoctors”. The medicine andnursing framework aims to fur-ther develop and redefine thequality of medical and nursingservices, as well as the form ofcooperation between profes-sional groups.

Mistakes and minimising riskby applying the 4-eyes“hands” principle

The aim of the “morning work”guideline is to improve patientsafety in the field of medical“morning work”. The period from7.00 to 9.00 a.m. has been de-fined as a potentially dangeroustime. It was therefore decidedthat doctors and nurses shouldcarry out their routine morningwork together.

However, this 4-eyes principleis also applied as a quality as-surance measure following on

from morning work in potential-ly dangerous situations such asadministering stored blood,chemotherapy and the like.These dangerous situations aredetermined by each depart-ment, including all relevant pro-fessional groups. This depart-ment-specific regulation is ondisplay on the ward and shouldbe brought to the attention ofeveryone. It is checked to en-sure it is up to date as part ofan annual multi-professionaldepartment discussion.

The 4-eyes principle makes pa-tient safety during potentiallydangerous activities the focusof attention.

Admission anddischarge management

The admissions discussions ofnurses and doctors have beencoordinated. Duplications of workare thus avoided. Patients haveto be informed of the importanceof their attendance at the sched-uled visiting and treatment timesat the informed consent discus-sion, provided this is not prohib-ited for medical organisationalreasons. Each department mustdefine the admission and dis-charge process in writing. Admis-



By Josef Smolen, Gerda Sailer and Wilhelm Strmsek

DUAL MANAGEMENT AT THE DEPARTMENT LEVELDeveloping Process Structures and Framework Guidelines in Vienna’s Hospitals



sions planning and dischargemanagement are organised ona multi-professional basis. In thecase of discharge management,particular attention is also paidto the social needs of patientsfollowing their in-patient treat-ment. To that effect, cooperationis sought out and upheld withinthe established area, home-helps,rehabilitation centres and indi-vidually with family members. Agradual transition from the resi-dential care of hospitals to theextramural supply chain is es-sential; to offer patients the high-est possible quality of care andto make the best possible use ofall associated resources.

Improving cooperation between professional groups

Planned minimum presences ofemployees of all professionalgroups should be laid down inwriting and adhered to for eachoperational unit. In addition,multi-professional workflowsare coordinated and estab-lished in a spirit of process op-timisation. Team developmentprocesses are promoted (e.g.joint team meetings, joint su-pervision, multi-professionalfurther training).

Target agreements

Each year target agreementtalks are held between the dualmanagement of the depart-ments and their colleagues inhospital management. Depart-ment and investment budgets

with regard to the hospital’s pre-defined economic plan, targetsin relation to bed and staff man-agement, possibilities for opti-mising methods of billing med-ical services, and variouscontent-based objectives (re-lating to complaints manage-ment, risk management, andquality management) are dis-cussed and agreed.

Department budgets

The operating expenses budg-et for drugs and medical treat-ment requirements is brokendown on the basis of figures andperformance plans at depart-

ment level. Monthly controllingoverviews and close doctor,nurse and administration co-operation, allow anomalies tobe identified promptly andcountermeasures introduced.On top of this it is vital that in-novations in treatment areplanned in advance and imple-mented accordingly.

Internal hospital committees(e.g. committee for new medicalconsumables) or standardisa-tion groups for various areasmaintain close contact with thedepartments’ dual manage-ments. Improvements can eas-ily be achieved here throughfeedback mechanisms.

Monthly controlling informationand associated controlling talkswith the department manage-ment are necessary to identify

and fathom anomalies and joint-ly take appropriate controlmeasures. Savings in the de-partment budget are availableto the department for other pur-poses (investments, furthertraining, etc.). The budgetaryfunds saved must also be dis-tributed and prioritised consen-sually per department.

Investment plans are prioritisedand applied for jointly with con-sideration for reinvestments andnew purchases in the medico-technical sphere, amortisationprojects and facilities (with re-gard to the “hotel components”and nursing requirements).This

planned “bottom–up” budget-ing is checked for plausibility in-ternally and discussed and ne-gotiated with the owner each year.

Bed and staff management

Staff deployment planning in themedical and nursing servicesmust be planned, coordinated,and organised jointly. This is in-creasingly important becauseflexible working hour models arebeing pushed through, and atthe same time over-long dailyand weekly working hours are tobe reduced. Because of the in-creasing flexibility, also with re-gard to the utilisation of oper-ational spaces, functional bedand staff management in situ isessential.

With the support of the admin-istration, various working hours

models are being adapted to therequirements of each depart-ment and implemented accord-ingly. Here too it is increasinglyworthwhile first planning suchmodels as pilot projects, anal -ysing the results and then im-plementing them in, where nec-essary, improved form.

To organise patient care as ef-ficiently as possible, an ever-growing number of services arebeing offered at daily clinics (dai-ly admissions for suitable oper-ative or non-operative servic-es) or at weekly clinics (servicespectrum of smaller plannabletreatments with no more thanfive-day stays in a continuousoperation early Monday to Fri-day evening). Naturally, achiev-ing this optimal patient mix tomaximise utilisation (day pa-tients, week patients, normalward operation) requires a pro-fessional department and ad-mission/discharge managementcoordinated across all profes-sional groups.

Conclusion

The many examples cited showthat managing the core tasks ofhospitals’ individual departmentsis becoming increasingly impor-tant. A harmonic and coordinat-ed dual management scheme incollaboration with other opera-tional centres appears essentialfor the benefit of patient care,patient safety and satisfaction,as well as for economic success.

Authors:Hr.Univ.Prof.Dr.Josef Smolen, Board of Directors of 2d medical division, Centre for Diagnostic and Therapy of rheuma diseases, Neurological Centre Rosenhügel, Vienna, Austria Fr.Mag. Gerda Sailer, Head Nurse of 2d medical division, Neurological Centre Rosenhügel Hr. Oberamtsrat Wilhelm Strmsek,MAS, Managing Director of Neurological Centre Rosenhügel



In Vienna’s hospitals process, structures and frameworkguidelines have been recently implemented to effectivelycarry out shared activities between medicine and nursing.The 4-eyes principle makes patient safety during poten-tially dangerous activities the focus of attention.



OMS offerings have de-veloped from the real-time computer systems

used in radiotherapy (RT) de-partments, mainly with linear ac-celerators, to control treatmentdelivery. Complex daily treatmentfractionation is tracked throughRecord and Verify (R&V) mod-ules that maintain a completerecord of each radiation beam’scontribution to the overall dose.

OMS Components

R&V modules and the machineverification aspects are special-ist and unique RT features, nowincorporated into OMS systems.These encompass other mod-ules covering from medical his-tory, to record tumour diagno-sis and staging, scheduling, notonly for patient preparation andtherapy attendances, but alsofor activities in treatment prepa-ration that do not involve pa-tient attendance. Additionally,with modules for the organisa-tion and delivery of Chemother-

apy (Chemo) regimes and RTprotocols, concurrent treat-ments can be tracked. Clearlythis OMS functionality now over-laps with some features found in‘top-down’ Hospital InformationSystems (HIS).

OMS Structural Options

OMS suppliers serve the inter-national market and can offerindependent systems or cancreate hybrid systems by linkingOMS with DICOM to related RTsystems and to PACS, and withHL7 to HIS systems dealing withdemographics and more. Onecan also envisage systems inwhich almost all oncology records

are maintained on the main HISsystem. The departmental sys-tem would then receive treat-ment machines requests for work-lists and treat ment parametersfrom the HIS and in turn submittreatment delivery records backto the HIS. The growing maturi-ty of the RT extensions to theDICOM standards and theiradoption across the communi-ty makes moves towards thismodel potentially possible, al-though the many unresolved in-tegration issues suggest that thehybrid system model is the prag-matic choice for now. Whatev-er model is adopted, within thesphere of oncology the appro-priate use of OMS technology

can considerably aid the processof achieving the necessary clin-ical, efficiency, financial and gov-ernance objectives.

Benefits to RT Processes

Patient pathways through on-cology are complex, involvinginput from various profession-als. Developments within OMSintroduce the possibility of ac-tively tracking ‘back-office’ taskssuch as tumour delineation onplanning images and the subse-quent RT planning processes.Careful mapping of preparationprocesses and available staffskills makes it possible to deviseways in which the scheduling ca-

The selection and integration of appropriate information systems is one of thechallenges facing hospital managers in their quest to achieve organisations of-fering a high level of clinical care, coupled with efficiency, and good financialand clinical governance. The issues become particularly difficult when ‘top down’systems, such as EHR, HIS and PACS come into contention with established de-partmental systems. This article considers Oncology Management Systems (OMS),where issues of integration between departmental systems and corporate sys-tems currently engender debate.

By Andrew Hoole and Edwin Claridge

SHOULD WE BUY ANONCOLOGY MANAGEMENT SYSTEM? A Mini HIS for Oncology

M E D T E C H


An OMS is now a critical component in the day-to-dayoperation of Oncology facilities and a potentially richdata resource for management to meet larger goals.



pabilities of an OMS can be usedto more clearly define and allo-cate the associated tasks with-in the processes. This precisedefinition and allocation of taskscan also improve the sense ofownership, accountability andcontrol that staff feels. Suchtechniques also enable the au-dit of pathways. This kind of au-dit highlights areas of resourcebottlenecks, enabling managersat all levels to address such is-sues by training or physical re-source provision. The need tomeet stringent waiting time tar-gets requires the overall processto be intelligently controlled.

Over the past decade or so thetechnology behind RT andchemo has increased in com-plexity. The ability to safely uti-lize new technologies has beendue largely to the parallel de-velopment of OMS, handling in-formation on patient configu-rations, image guided RT, or thecomplex regimes associated withchemo. As treatment complex-ity increases, it is important thattreatment management doesnot become fragmented acrosstoo many information systems.This would increase the difficul-ty of maintaining an overall pic-ture of a patient’s treatment.Potential conflicts arise in thatcontext, such as whether it isbest to have a chemo prescrib-ing system that serves clinicsdistant from a cancer centre andis part of an OMS, or whether itis better to prescribe chemofrom individual hospital phar-macy systems?

Other Advantages

Integration: To achieve good in-tegration, OMS providers shouldbe encouraged to provide solu-tions that both embrace the new-ly developing technologies andthat integrate with HIS and oth-er corporate systems. This is mostlikely to be achieved by ensuring

that systems support develop-ing standards, for example, HL7for general message passing, andthe maturing RT components ofthe DICOM standard, for PACS in-tegration, both encouraged bythe Integrating the HealthcareEnterprise (IHE) initiatives for ex-changing data between systemsusing agreed definitions.

Time and space management:Oncology management falls atthe complex end of the spec-trum of hospital activities. Workis largely out-patient orientedand both RT and chemo are like-ly to involve many treatmentsessions. The scheduling is com-plex because slots in treatmentbays and rooms are used so in-tensively. The treatment path-ways are many; their modifica-tion as treatments regimes andprotocols progress is quite com-mon. When using an OMS data-base a distinction between ac-tivities concerned with theprovision of patient treatmentand those intended to providemanagement statistics needs tobe appreciated. For costing/billing and process/revenue al-location managers must choosebetween collecting large vol-umes of daily data from incom-plete prescriptions, or lower vol-umes of summary data, whichhas been through more qualityscreening and deals with finishedprescriptions. For monitoring theuse of treatment rooms, the var-ious waiting times and the tech-

niques in use, the OMS is also arich resource.

Dissemination of information:A challenge for the oncologycommunity is to make local dataappropriately available acrossa broader spectrum in a man-ner that is not open to misinter-pretation; uses could include au-dit and resource planning.Un fortunately the terminologyused in oncology and OMS is notstandardised and comparisonsbetween centres are thereforedifficult. The wide availability ofPACS systems, themselvesbased on the DICOM standardand in some countries becom-ing integrated across the nation,make them a potential platformfor achieving this wider dissem-ination of information. The op-erational differences betweenradiology and oncology de-partments make it difficult to en-visage a real-time integrationwith OMS, but the retrospectiveuploading of a completed RTepisode summary DICOM dataobject into PACS is a potentialway in which this data may be“protected” for the benefit ofthe patient across a broader ge-ographical spectrum.

Data security: Data protectionis often viewed as ensuring thatdata does not fall into the wronghands. Another important as-pect is to ensure that the dataheld remains available for con-tinued use, in the context of both

current and future treatments.The centralised storage of datain local OMS facilitates thisprocess. Note that statutory On-cology data storage periods areusually greater than many OMSsoftware life cycles, implying thatevolutionary planning must in-clude archive data.

Conclusion

In conclusion an OMS is now acritical component in the day-to-day operation of Oncologyfacilities and a potentially richdata resource for managementto meet larger goals. Current-ly the level of integration, forexample for the assimilation ofOMS elements beyond R&Vinto HIS and/or PACS, is notcompletely developed. Thestandards for the definitionsrequired for national and inter - national data exchange havealso not yet been agreed. It isnecessary to consider these is-sues when purchasing an OMSsolution and essential to en-gage in an active debate aboutfuture relationships betweenOMS, HIS and PACS.

Authors:Andrew Hoole, Edwin Claridge,

Informatics and Computing Special

Interest Group (ICSIG), The Institute

of Physics and Engineering in Medicine

(IPEM), York, United Kingdom

Email:

[email protected]


Patient pathways through oncology are complex,involving input from various professionals. Developments within OMS introduce the possibilityof actively tracking ‘back-office’ tasks such as tumour delineation on planning images and thesubsequent RT planning processes.



History

During the 14th century, Lithua-nia was one of the largest coun-tries in Europe: Belarus, Ukraine,and parts of Poland and Russiaused to be territories of the GrandDuchy of Lithuania. With theLublin Union of 1569 Poland andLithuania formed a new state, thePolish–Lithuanian Common-wealth. The Commonwealth lastedmore than two centuries, untilneighbouring countries sys tem - a tically dismantled it from 1772to 1795, with the Russian Empireannexing most of Lithuania's ter-ritory. In the wake of the FirstWorld War the sovereign statehad been reestablished but in1940, Lithuania was occupied firstby the Soviet Union then NaziGermany. As World War II nearedits end in 1944 and the Nazis re-treated, the Soviet Union reoc-cupied Lithuania. On March 11,1990, Lithuania became the firstSoviet republic to declare its re-newed independence.

Institutions

The Lithuanian head of state isthe President, elected directly fora five-year term, serving a max-imum of two consecutive terms.The post of President is largelyceremonial; main policy functionshowever include foreign affairsand national security policy. ThePresident, with the approval ofthe parliamentary body also ap-points the prime minister and onthe latter's nomination, appointsthe rest of the cabinet, as well asa number of other top civil ser-vants and the judges for all courts.The unicameral Lithuanian par-liament, the Seimas, has 141members who are elected forfour-year terms. 71 of the mem-bers of this legislative body areelected in single constituencies,and the other 70 are elected ina nationwide vote by proportionalrepresentation.

The litas, the national currency,has been pegged to the euro

since February 2, 2002 at the rateof EUR 1.00 = LTL 3.4528, andLithuania is expecting to switch tothe euro on January 1, 2011.

Lithuania is a member of theWorld Trade Organisation, andthe European Union (Since May2004). Lithuania became a fullmember of the Schengen Agree-ment on 21 December 2007.

Economy

During the last five years Lithua-nia has had one of the highesteconomic growth rates amongEU candidate and member coun-tries, reaching 10.2% in 2003 and8.9% in 2007. Fast growth hasradically changed the country’srelative figures. In 2001 the GDPper capita in Lithuania was 41%of EU27 level, reaching 61% in2007.

Fast economic growth has alsocontributed to improvementsin social indicators with unem-

THE LITHUANIAN HEALTH SYSTEMBy Gediminas Cerniauskas and Janina Asadauskien

Lithuania, officially the Republic of Lithuania, is one of the three Baltic

States. Situated along the southeastern shore of the Baltic Sea, it shares

borders with Latvia to the north, Belarus to the southeast, Poland, and the

Russian enclave of the Kaliningrad Oblast to the southwest. Lithuania is a

member of NATO. Its population is 3.4 million, declining during the last

decade because of demographic factors and negative migration. Its capi-

tal and largest city is Vilnius.

C O U N T R Y F O C U S


v



ployment rate decreasing from16.5% in 2001 to just 4.3% in2007, but provoked growth ofinflation from 1.6% in 2001 to5.8% in 2007 and up to 10% in2008 and unsustainable levelsof current account deficits.

Mounting internal pressures incombination with the gloomy in-ternational environment is slow-ing economic growth in 2008 to3-4% and there is a risk of fallingin to recession in the first quar-ter of 2009. The slowdown will hitthe healthcare sector, which wasgrowing during the last years inline with the general economicgrowth. At least in 2009 positivetrends in long-term social stabil-ity will not be affected, i.e. thenumber of births was 30.5 perthousand in 2005, 32.3 per thou-sand in 2007 and will reach about35 per thousand in 2008.

Health System

The healthcare system in Lithua-nia is designed according to thebasic principles common to Eu-ropean cultures. Universal accessto basic medical services is grant-ed to the whole population. Ba-sic medical services are mainlyfree of charge for the consumerand mostly financed accordingto a solidarity-based scheme ofstatutory health insurance oper-ational since 1997. From the startfunding was raised according toa mixed model: about 50% ofhealth insurance funds came fromgeneral income tax (30% of thetax was allocated to health in-surance); 3% of payroll tax andcontributions from the statebudget for pensioners, unem-ployed and children, contributedfor the residual part.

As of 1 January 2009 this modelhas been modified: special healthinsurance contributions at thelevel of 6% of payroll will replace

allocations from general incometax. The change will mean thatabout 75% of statutory health in-surance revenues will be gener-ated by health insurance con-tributions (HIC) and 25% bycon tri butions from the state bud -get and other sources of mar-ginal importance.

The relative increase of importan -ce of HIC means that the systemis moving closer to the Bismarckmodel but certain dif fe rences be-tween the two will remain:

The statutory health insurancefund in Lithuania is a semi autonomous state monopolyunder the Ministry of Health(MOH) referred to as theState Patient Fund (SPF);Contributions, benefit packages,price providers are fixed bylaw or state authorities, andFormulas to assure regionalequity in funds distribution toregional branches of SPF arein place.

So far the statutory health insur-ance scheme has been in bal-ance, whether they are going tobe as successful during the peri-od of incoming hard times re-mains to be seen.

Coverage

Most dental and spa services arenot covered by the publicscheme and almost no copay-ments are applied to generalhealth services. There have beensome suggestions to introducemarginal copayments for certainhospital services and certaintypes of modern technologiesbut until recently there was nopolitical will to introduce thosemeasures. Even taking into ac-count the fact that copaymentsbased on reference pricing arecommon for medicines and oth-er medical goods, the limited

scope of copayments results inthe virtual absence of supple-mentary forms of health insur-ance. In the fall of 2008 the gov-ernment opted for a nationalimplementation of medical sav-ings accounts supported by taxsubsidies, but this decision is stilljust a political statement.

Hospitals

The provision of healthcare isshaped in a pyramid form withuniversity hospitals at the top, afew regional hospitals with a ma-jority of services except organtransplants and sophisticatedtesting procedures provided onthe high end, municipal hospitalsproviding ordinary therapeuticand surgical services as well asnursing in the middle and primaryhealthcare institutions at the bot-tom. Special units of most hos-pitals provide specialised outpa-tient health services.

Polyclinics that at the beginningof market reforms were consid-ered as rudiments of a Semashosystem and had to be closed areflourishing in some private clin-ics and big cities today. Privatepractices are mainly concentrat-ed in dental care with no publiccoverage and in family care withpublic funding based on an ageadjusted capitation model andsome incentives for screeningand other services considerednational priority. Roughly 80%of the labour force of about80,000 in the healthcare sec-tor are public employees withvery slow dynamics towards be-coming employed by private en-tities or self-employed.

National Health Council

The Lithuanian Health Programmewas prepared and approved bythe Seimas in 1998 in line with theimplementation of the European

health policy "Health for every-one in the twenty-first century"and the provisions of the Law onHealth System passed in 1994,legitimating an active health-care policy.

The common objectives of thisprogramme are:

Reduction of mortality rates and increase of life expectancy;Equity of access to healthcare, and Improvement of quality of life.

The specific indicator levels toreach were determined accor -ding to specific objectives con-cerning cardiovascular dis-eases, cancers, accidents andinjuries, mental illnesses, infec-tious diseases, oral health anddiabetes mellitus.

The National Health Council wasestablished to create an inde-pendent institution accountableto the parliament, consisting ofleading figures among publichealth professionals, researchersand community activists, localgovernments and non-govern-mental organisations repre-senting the interests of publichealth. The council is composedof 15 members representingthese groups with the mission ofcontributing to the formulationof a modern public health con-cept and implementation ofhealth policies. Its role:

To analyse health promotion processes;To assess the practical implementation of health policies, and To provide conclusions, suggestions and recommendations around the improvement ofperformance of lifestyle,environment and healthcare services.





The Council has the authority,while considering problems, toinclude all strata and socio-economic sectors of society,which, as referred to in the Maas-tricht Treaty approved in 1992,must assume the responsibilityfor the health of its people. Thelegal basis of the Council’s ac-tivities is established in the Lawon Health System of the Repub-lic of Lithuania, and regulationsare approved by resolutions ofthe Lithuanian Parliament.

The National Health Council as-sesses population health trends,their relationship to the social andeconomic policy decided by thestate, provides information to theSeimas, government and socie-ty, prepares and submits an an-nual report to the Seimas on thepopulation’s health conditionsand health policy formulation,and at their discretion provides

suggestions to the governmentand Seimas on draft laws andother legislation.

Conclusion

Assessing key population healthindicators in Lithuania, one mayconclude that measures towardschanging health markers are stillneeded. There have been signif-icant positive developments onlyin the area of infant mortality re-duction. In 2004, the infant mor-tality rate in Lithuania was betterthan the European average. How-ever, it is disappointing that theformer significantly positive trendsof health indicators (in particular,mortality) from 2000 tend to benegative. Morbidity and mortali-ty rates of the country's popula-tion from cancer, cardiovasculardisease, spreading of HIV/AIDSand drug problems, smoking andalcohol consumption among chil-

dren and adolescents are all in-creasingly growing.

One should note that without in-vesting in the public health sector,without attracting other country’ssectors of the social eco nomicframework into the processes ofthe health sector, the possibilitiesof the health sector itself will grad-ually decline. If governmentalstrategy for dealing with healthproblems does not change, it willbe virtually impossible to achievethe accelerated improvement ofhealth indicators.

In order to implement the set ob-jectives one needs a balance andsufficient funding for all areas af-fecting health:

Competent and methodical process control;Definition of responsibilities and accountability for the

obligations imposed;Division and reorganisation of functions among public health institutions;Identification and education of health sector entrepreneurs,andMaturation of society,politicians, and media.

It is expected that the success-ful implementation of theLithuanian Health Programmeprovisions will help to achievesubstantial changes in creatinga healthy and happy society.Health policy must be compre-hended by everyone as an in-vestment in the future, ratherthan as cost.

Authors:Gediminas Cerniauskas, Former Minister of Health of the Lithuanian Republic.And Janina Asadauskien


RECENT CHANGES IN LITHUANIANHOSPITAL ACTIVITIES By Edmundas Baltakis

Since restoration of Lithuania’sindependence in 1990, the mostsignificant changes in the coun-try’s health system have takenplace in the area of inpatienttreatment. Lithuania inherited anexpensive model from the Sovi-et Semashko system; a systemin need of refocusing on the mar-ket model by a gradual reduc-tion of inpatient beds and hos-pital network. This process wascarried out in several stages.

Facts and figures

In 1990 there were 198 inpatienttreatment institutions in thecountry: 8 state and universityhospitals, 7 republican rehabili-tation hospitals, 3 scientific re-

search institutes, centres andclinics, 20 city hospitals, 1 chil-dren’s hospital, 4 maternities, 78district hospitals, 31 small neigh-bourhood hospitals, 7 nursingand 24 specialised hospitals (3hospitals of infectious diseases,10 of tuberculosis, and 2 of skin,venereal diseases, 8 psychiatrichospitals). In addition to these,there were 15 facilities with sta-tionary departments (tubercu-losis, skin - venereal diseases,oncology, psycho neurological,rehab centres).

Thus, in total there were 46,175hospital beds in the country,and 124.73 beds per 10,000 in-habitants, 2.5 times above theEU average.

Number of beds

During the period of 1990-2000(in 1997, hospitals became pub-lic institutions) the number of in-patient hospitals established inthe country experienced littlechange and at the end of 2000there were 187 establishments.However, during the currentdecade, the number of beds hasdecreased by 26 percent (12,000).The most significant decrease wasnoted in the therapeutic, obstet-rics-gynaecology and surgerytype of beds. Many small hospi-tals have been converted to nurs-ing and supportive treatmentunits. In 2000, nursing and sup-port treatment hospitals had3,233 beds (9.2 beds per 10,000

inhabitants), but their territorialdistribution was uneven.

Until 2000, there were no privatehospitals in Lithuania.

Hospitalisations

In 1990 hospitalisation rates were18.68 cases per 100 inhabitants,and it grew until 1999, when itreached 25.69 cases. There aretwo main reasons for this in-crease: a difficult economic sit-uation after the restoration ofindependence with high inflation,increased morbidity and reper-cussions of the Russian crisis, butalso the transition to a new fund-ing system in 1997; after the in-troduction of medical insurance


v





and without any quota for inpa-tient services, many patients werehospitalised because it was fi-nancially beneficial to hospitals.

Restructuring

In 2003 the government ofLithuania adopted a resolutionon the restructuring strategy ofhealthcare facilities. Healthcareestablishments were to be re-structured in two phases - thefirst period in 2003-2005, andsecond in 2006-2008.

Among many problems the mostimportant was to restructure thenetwork of healthcare institutions,by improving the efficiency ofhealthcare facilities, reducing in-patient services and acceleratingthe expansion of a wider range ofambulatory health care services.

While the country's inpatient in-stitutions were being restruc-tured, day care, day surgery andoutpatient rehabilitation servic-es were significantly developed.During the restructuring process,

specialised tuberculosis, in-fectious, gerontology, psycho-somatic, eyes, ENT and otherspecialised units were closedin many municipal and regionalhospitals, and these serviceswere transferred to the multi-profile, specialised sections ofdistrict and university hospitals.

In the country's largest cities Vil-nius, Kaunas (and others), hos-pitals were merged and groupedtogether. Thus, by the end of2006 the country already coun -t ed only 104 hospitals with a le-gal status.

Compared with 2000, the num-ber of inpatient institutions fell byas much as 44.4%, and accord-ingly, the number of hospital bedsdeclined by 41.3 percent, where-as the number of beds per 10,000of population was 80.1.

Consequences of Restructuring

The hospitalisation rate from2000 until 2007 gradually de-

clined and reached 20.3 cases per100 inhabitants, i.e. fell by morethan 10 percent.

The results of the first restruc-turing phase of healthcare in-stitutions indicated that specif-ic changes have taken placeregarding the basic indicatorsof the country's healthcare sys-tem: a significant decrease ofinpatient beds in the country’sinstitutions and a hospital ad-mission rate per 100 inhabitantsthat fell from 23.2 to 20.9 of pa-tients. The average length ofstay was 2.2 days less, goingfrom 10.2 to 8 days, and the oc-cupancy of beds increased from284 to 308 days.

In 2007, compared with 2006,healthcare institutions provided675,000, i.e. 10% more priorityservices (outpatient specialist,acceptance and emergency as-sistance, day care, day surgery,observation, short-term treat-ment). During that period, thenumber of inpatient hospitalservices was reduced by 11%.

Within the framework of goals andtasks required in the secondphase of restructuring in the in-patient area, there are plans tofacilitate the infrastructure ofconsultative outpatient facilitiesand emergency (reception) de-partments, and to develop out-patient rehabilitation services,day hospital and day surgery.

In addition, the optimisation ofhospital activities requires mu-nicipal hospitals to enhance theinfrastructure of departmentsfor treatment of the most com-mon and easy to treat diseasesand to concentrate the diag-nosis and treatment of complexdiseases in university hospitalsand hospitals in large cities, byproviding them with sufficientmodern equipment and latesttechnologies.

Author:Edmundas Baltakis, Vice-president of the Association of Hospital ManagersPhysicians of Lithuania, Head Doctor of Joni_kis Hospital, Lithuania


Founded in 1991, the Associationof Hospital Managers Physiciansof Lithuania grew significantlyduring its first decade of exis-tence: its membership extendednot only to the managers ofhealthcare facilities, but also toother people working in the fieldof healthcare establishments. In2004 the Association evolved:it updated its charter, structured

itself as an association as far aslegal entities, and their managers(true members), other seniorhealth staff (associate members),and honorary members are con-cerned. The growth in the num-ber of members of the associa-tion indicates that the activitiesand efficiency of the associationhave an operational significance.Over the last five years, the num-

ber of members of the associa-tion increased from 50 to 114. Itinvolves another 80 associatemembers in its activities.

The EU Dimension

Our association was accepted asa member of the European As-sociation of Hospital Managersduring the EAHM Congress in the

city of Tampere (Finland) in 1996.This membership opened up newopportunities for our associa-tion: we were offered the oppor-tunity to participate in con-gresses and other events, tocommunicate directly with ourEuropean colleagues and to fa-miliarise ourselves with the healthsystems of the old and new EUmember states. We learned of



THE ASSOCIATION OF HOSPITAL MANAGERS PHYSICIANS OF LITHUANIA

By Stasys Gendvilis

Our History, Our Activities and Our Priorities



their experiences and the effec-tiveness of already accomplishedreforms and issues through a va-riety of channels, including Hos-pital magazine.

Our Mission

The association's mission is tounite the members of the asso-ciation for joint actions, gatherthem around issues ranging fromrearranging and improving theperformance of healthcare in-stitutions, to upgrading the qual-ity of healthcare services, im-proving their organisation,shaping health policy in coop-eration with official bodies, andparticipating in the activities ofinternational institutions and or-ganisations.

Recently, the association has de-cided to focus mainly on:

Training programmes for our members;Organising and coordinating the management of staff skills development; Researching new funding sources for healthcare facilities, and Disseminating information among the association members about the new innovative health service delivery methods and forms of work organisation.

Training Programme

As managers of Lithuanianhealth care facilities are gener-ally medical doctors, our asso-ciation deems it essential to im-

prove their managerial, legal andeconomic knowledge and skills.We have thus decided to or-ganise the Lithuanian HealthSystem Development, whichconsists of professional devel-opment training courses for allhealthcare managers. Pursuingthis work, we are currently or-ganising a joint project of all as-sociation member institutions,partly funded from the EU struc-tural funds, in order to continuethe training and knowledge im-provement of our associationleaders and their staff - doctors,nurses and other specialists inthe managerial and profession-al fields.

Cooperation with Governmental Bodiesand Activities

Economic recession and finan-cial hardship are prevailing rightnow in Lithuania, as in manyother countries. The country'sparliamentary elections tookplace at the end of 2008, witha subsequent change of gov-ernment. The new governmentis preparing a stabilisation planof the country's financial andeconomic system.

Our association is working hardto propose the changes that willsignificantly and positively affectthe financing of our country’shealth system management, aswell as the principles of transfor-mation and strategic trends for2008-2012. Our association isalso involved in medical com-munity building activities.

After Lithuania‘s accession to theEU and the establishment of thefree movement of citizens, goodsand services, a large number ofhighly trained doctors from ourcountry left to work abroad. Forthis reason we are now facing ashortage of doctors, particular-ly in remote parts of the coun-try. The association has repeat-edly proposed solutions to thishuman resources problem to thegovernment, ministry of healthand medical universities.

Recently the association partic-ipated, along with the Ministry ofHealth and State Patient Fund,in the European Union’s new ini-tiative on patients' rights and en-suring the freedom of movementand the right to the necessaryassistance for the insured in EUmember states. It analyses thecooperation and the implemen-tation of the European Parlia-ment and Council Directive onpatients' rights to healthcareservices in other member states.The country has few privatehealthcare institutions (with theexception of family clinics, anddental care). Consequently theassociation often addresses theissue of rational approaches topublic-private partnership, andpromotes cooperation betweenpublic and private sectors.

Quality and E-Health

The constant focus of our asso-ciation activities is the questionof maintaining the quality ofhealth services. Quality and safe-

ty can be ensured by a system ofinstitution accreditation. Welearned about the accreditationsystems most often applied in Eu-ropean hospitals, and a largenumber of our institutions havealready implemented qualitymanagement systems and Euro-pean certificates of management.

Managers of healthcare facili-ties are also greatly interestedin e-health issues. The associ-ation is involved in the develop-ment of e-health strategies inthe country. It aims to create anddevelop e-health services in in-stitutions, and encourages pa-tients to use them.

In many institutions, an electronicadvance patient registration sys-tem is being implemented; sep-arate elements of the hospitalinformation system in medicalinstitutions, and a unified nationalelectronic health system are be-ing developed.

Conclusion

In recent years, especially afterLithuania's accession to the EU,big changes have taken place inthe country's healthcare system:our legislation was adapted ac-cording to European standards.All healthcare institutions are nowsubject to the same modern di-agnostic and treatment tech-nologies; hospitals and clinics aremanaged and renovated. We arepleased to note that the man-agers of healthcare institutions,who are members of our asso-ciation, take the most active partin these processes.

Author:Stasys GendvilisPresident of the Association of Hospital Managers Physicians of LithuaniaGeneral Director of Kaunas district hospital, Lithuania



The constant focus of our association activities is thequestion of maintaining the quality of health services.Quality and safety can be ensured by a system of institution accreditation.



Les éditoriaux d’(E)Hospital sont rédigés par des membres des instances dirigeantes de l’AEDH. Les contributions publiées ici ne reflètent cependant que l’opinion de leur auteur et ne représentent en aucune façon la position officielle de l’AEDH.

LE SYSTÈME DE SANTÉ FRANÇAIS EN PLEINE MUTATION

A l’instar de ses voisins européens, lesystème de santé français est con-fronté depuis plusieurs années à desproblématiques lourdes. Celles-ci semanifestent certes selon des formesdifférentes, mais ont toutes les mêmesorigines: raréfaction des ressourceshumaines médicales, augmentationtrès forte des dépenses de santé cou-plée à d’importantes tensions budgé-taires, difficulté à concilier la néces-saire proximité des établissements desanté avec l’exigence de sécurité dessoins qui impose une concentrationdes équipes soignantes et desplateaux techniques…

Dès après son élection à la Prési-dence de la République, NicolasSarkozy a fait part de sa volonté deproposer une nouvelle organisationdu système de santé français. C’estainsi qu’à l’issue d’une large con-certation, le projet de loi Hôpital –Patient - Santé - Territoire a étéprésenté aux hospitaliers.

Inspiré d’expériences concluantesmises en œuvre en Europe cesdernières années, ce projet de loi seraexaminé au cours du premier se-mestre 2009 par le Parlementfrançais et devrait apporter des évo-lutions majeures:

En premier lieu, le projet de lois’attache à redéfinir la notion deservice public hospitalier en pré-

cisant que ces missions peuvent êtreassurées par tout établissement desanté, qu’il soit public ou privé.L’ambition du gouvernement est defaire porter sur tous la charge et lescontraintes de ces missions de ser -vice public et de permettre ainsi unemeilleure efficience du système.

L’autre innovation majeure résidedans l’introduction de la notion de «territoire de santé » et dans la créationde communautés hospitalières de ter-ritoire, structure formalisée de coopéra-tion entre établissements publics d’unmême territoire. Tout en conservantleur autonomie juridique, plusieurs étab-lissements d’une même zone serontainsi incités à définir une stratégie com-mune, à partager leurs ressources hu-maines, à concentrer leurs plateauxtechniques en un seul lieu…

Parallèlement à cette territorialisa-tion accrue, des Agences Régionalesde Santé vont être mises en place dèsjanvier 2010. Dotées de missions etde pouvoirs plus larges que lesactuelles Agences Régionales del’Hospitalisation, les Agences Ré-gionales de Santé seront chargéesde définir et mettre en oeuvre unepolitique régionale de santé, qu’ils’agisse de la politique hospitalière,de la politique de santé publique, dessoins ambulatoires, ou encore de lapolitique médico-sociale. Annoncéesdepuis de nombreuses années, ces

Agences devraient permettre ausecteur hospitalier et non hospitalierde développer leur complémentarité.

Enfin, la nouvelle loi devrait apporterdes innovations dans le managementinterne des établissements de santé:évolution profonde des organes dé-cisionnels des hôpitaux, renforcementdes pouvoirs du directeur d’établisse-ment, renforcement du rôle des pôlesd’activité médicale et de leurs com-pétences, mais aussi création de nou-velles formes de contrats de travaildestinées à améliorer l’attractivité descarrières hospitalières en permettantnotamment de lier la rémunération àla performance individuelle des ac-teurs du système de santé.

Dans un contexte en profonde mu-tation, il est plus que jamais indis-pensable pour chaque décideur hos-pitalier de s’inspirer des actionsdéployées dans les autres Etats pourfaire face aux mêmes types de pro-blèmes. C’est pour cela qu’en 2009,l’AEDH inscrira fortement son actiondans cette recherche de conver-gences entre les acteurs hospitalierseuropéens qui seule permettra deconstruire, pas à pas, une Europe dela santé forte et cohérente.

Excellente année 2009 à tous !

Paul CastelPrésident de l’AEDH

Paul Castel


A E D H - F R A N C A I S>




N O U V E L L E S D E L ’ A S S O C I AT I O N E U R O P É E N N E D E S D I R E C T E U R S D ’ H Ô P I TA U X

L’année dernière, notre organisationsœur, la Dansk Selskab For Ledelse ISundhedsvæsenet a décidé de créerun sous-comité international. L’ob-jectif était de promouvoir l’échange deconnaissances et d’expériences avecla communauté internationale; de sui-vre les développements mondiaux dela gestion des soins et de porter les ex-périences danoises au niveau interna-tional (voir (E)Hospital 5/2008).

En tant que point de départ à cette dé-marche, une délégation danoise de 14personnes est venue à Bruxelles endécembre dernier et y a combinéplusieurs rencontres. Le programmecomprenait une visite au Parlement

européen avec l’europarlementairedanois Karin Riis-Jorgensen et une réu-nion à la Commission européenne. Ladélégation s’est également rendue àla Représentation danoise à Bruxelleset a discuté avec les représentants ré-gionaux danois.

L’AEDH a accueilli la délégation dansses bureaux, en combinaison avec unevisite de la Clinique Saint-Jean. Legroupe a été informé des activités denotre association ainsi que des ques-tions d’actualité figurant à l’ordre dujour au niveau européen. La proposi-tion de directive sur les droits du pa-tient et les soins transfrontaliers a ou-vert une discussion autour de la qualité

des soins. La contribution qu’un mo-dèle d’accréditation pourrait apporterà la qualité a également été abordée,dans le droit fil du séminaire que l’AEDHa organisé en 2007 autour du mêmesujet. Le thème de la privatisation etla coexistence d’acteurs publics etprivés sur la scène hospitalière eu-ropéenne est une question tout aussiactuelle et sera le point central duséminaire mis sur pied par l’AEDH cetteannée (voir agenda). Les visionsdanoises et européennes à propos dela gouvernance hospitalières ont étééchangées durant cette entrevue, à lalumière de la récente crise bancaire etde la relation tumultueuse entre ges-tion hospitalière et financeurs.

UNE DÉLÉGATION DANOISE EN VISITE À BRUXELLES



Investissement en e-santéPar Alexander Dobrev, Tom Jones et Karl A. Stroetmann

L’étude récente, intitulée Financing eHealth, four-nit une guidance générale aux investisseurs po-tentiels en e-santé afin de les soutenir dans leurprocessus décisionnel. La leçon principale en cequi concerne les modèles à adopter est d’inté grerles décisions d’investissement en e-santé à lastratégie de soins de l’établissement. L’e-santépeut s’atteler à la tâche mais il faut qu’elle fassepartie intégrante du panel général de ressourcesmises en œuvre pour répondre aux besoins de soinsde santé. Le modèle de financement de l’in-vestissement ne devrait être envisagé qu’aprèsque l’analyse économique ait été effectuée.

L’exigence essentielle pour les dirigeants, cadreset acteurs de santé est d’être capable de traiterl’investissement d’e-santé comme une composantede l’investissement général de santé. Les ges-tionnaires financiers ont un rôle plus spécifique.D’abord, ils doivent comprendre la valeur et l’im-pact de l’e-santé, afin de pouvoir développer unplanning financier en concordance avec les pers - pectives d’investissement de l’e-santé. Ensuite, ilsdoivent utiliser pleinement leur compétences ma -nagériales pour pouvoir trouver les moyens d’in-vestir dans la valeur ajoutée.

Questions légales autour des TICs à l’hôpitalPar Jean Herveg

L’e-santé renvoie à l’application des technologiesde l’information et de la communication au secteurdes soins de santé. Elle se retrouve dans une largegamme de produits et de services dans le contextehospitalier. Depuis la gestion électronique des don-nées du patient ou du personnel, l’utilisation de latélésurveillance, de la téléchirurgie ou même laformation du personnel à distance. D’un point devue juridique, ces applications sont souvent ré-glementées par la législation sur le droit à la vieprivée et le traitement des données personnelles.Cependant, d’autres réglementations doivent aus-si être prises en considération selon l’approche etl’angle d’analyse. Elles concernent les lois surl’équipement, les services ainsi que la respon sabilitéde l’hôpital et la concurrence. Une grande majoritéde ces règles n’est pas propre au secteur sanitaireou hospitalier.

Sécurité du patient et e-santéPar Susan Burnett

Si on veut améliorer la sécurité du patient, il est impor-tant d’apprécier la valeur d’une approche systémiquedans la prévention et l’analyse des erreurs, en recon-naissant que le comportement humain est fonction dusystème dans lequel les gens travaillent. La sécurité dupatient doit être mentionnée en toutes lettres dans lastratégie de technologie de l’information de tout étab-lissement de santé et doit être au centre de tous les sys-tèmes en interface avec la technologie et le soin au pa-tient. Par exemple pour le département des ressourceshumaines, les questions concernent les besoins en per-sonnel et les compétences requises par rapport aux nou-veaux systèmes, l’utilisation de personnel temporaire quine sait éventuellement pas utiliser les applications, ain-si que la formation continue et la certification du per-sonnel ancien et nouveau pour l’utilisation de la tech-nologie. De nombreux établissements ont introduit denouvelles clauses dans les contrats de travail à proposde l’usage abusif de l’IT par exemple.

L’e-santé peut améliorer considérablement la sécuritédu patient, mais elle entraîne aussi des risques nouveaux.La direction hospitalière doit comprendre la théorie del’erreur humaine et la pensée systémique, et s’assurerque les systèmes managériaux appropriés sont en placepour les traiter.

ForumclinicPar I. Grau, J. Gene-Badia, E. Sanchez Freire, M. Bernardo et M. DeSemir

Forumclinic est un ensemble d’outils audiovisuels (DVDset site web) en espagnol et catalan lancé en janvier 2007afin d’améliorer la qualité de vie des patients chroniques.Basé sur le principe qu’en comprenant mieux leur maladieles patients deviennent plus autonomes, le projet vise àencourager l’implication du patient dans le processus dé-cisionnel clinique en collaboration avec l’équipe de santé.

C’est pourquoi des monographies ont été rédigées surla cardiopathie ischémique, le diabète, les maladies pul-monaires chroniques obstructives, la schizophrénie, lecancer du sein, la dépression et les facteurs de risquecardiovasculaire. Le portail combine un contenu d’in-térêt général en format texte et multimédia. Le blog per-met une interaction avec le public. Quatre types d’in-formation sont fournis : des données de base sur chaquemaladie, des nouvelles récentes les concernant, desvidéos et animations 3D et des forums de discussionsgérés par des professionnels.

> N O U V E L L E S D E L ’ A S S O C I AT I O N E U R O P É E N N E D E S D I R E C T E U R S D ’ H Ô P I TA U X




Face à une baisse du nombre de travailleurs de santé Par Bruno Marchal

Durant la dernière décennie, plusieurs pays européensont pris des mesures pour accélérer l’afflux dans les pro-fessions paramédicales et la rétention des cadres exis-tants, y compris par la création de nouveaux cadres deprofessionnels de santé, le recrutement d’infirmières àl’étranger, de meilleures rémunérations et l’introductionde conditions de travail plus souples. On a beaucoup moinsparlé de la façon dont les gestionnaires de santé peuventdévelopper des mesures pour attirer et retenir leur per-sonnel au-delà des incitants financiers ou des tentativesde recrutement dans le Sud. En fait, un management cen-tré sur l’engagement consiste à appliquer un ensemblecohérent de pratiques identifiées par Pfeffer:

une embauche sélective,la sécurité de l’emploi,une rémunération comparativement élevée en fonction de la prestation organisationnelle,une formation et développement institutionnalisés,des équipes auto-gérées, une décentralisation,une réduction des différences de statuts, et une dissémination de l’information.

Impact de l’externalisation sur l’emploi hospitalierPar Thilo Ullrich

Pour de nombreuses raisons, il est souvent plus senséd’externaliser certaines fonctions hospitalières plutôt quede confier ces tâches à l’hôpital. Ces raisons vont d’uneplus grande flexibilité à la possibilité de faire appel à uneexpertise professionnelle, un effet de synergie ou l’adop-tion de différents systèmes compensatoires. Quelle quesoit la méthode choisie, l’externalisation de services oude parties de l’activité soulèvera différentes questionsliées à l’emploi et au droit du travail, y compris le trans-fert de fonctions et les droits de participation aux or-ganismes de représentation, comité d’entreprise ou as-semblée du personnel.

Afin d’établir quels droits seront octroyés à chaque em-ployé, il est important de déterminer si la propositiond’externalisation aboutira à un transfert d’opérations.De plus, il faut également prendre en compte les droitsdu comité d’entreprise ou de l’assemblée du personnel,afin de prévenir des retards qui font perdre du temps etprovoquent des plaintes dispendieuses. Une bonne pré-paration juridique des plans d’externalisation peut doncéviter de nombreux problèmes et, à terme, faire gagnerdu temps et de l’argent.

Modification des heures de travail en chirurgie oncologiquePar Anne-Marie Teller et Pascale Witz

Les soins aux patients lourds ont d’importantes impli-cations physiques et psychologiques pour le personnelinfirmier. La gestion des soins, en collaboration avec ladirection générale et le département des ressources hu-maines, a offert au personnel la possibilité de passer depériodes de travail de 8 à 12 heures. Vu la nature déroga-toire du changement, il a été fait sur base volontaireavec une évaluation après 3 et 6 mois.

La réaction a été très positive du côté des patients quiconnaissaient «leur» infirmière pour la journée et aumieux les 2 jours suivants. L’atmosphère de travail achangé: les différentes spécialités ont pris consciencede l’impact organisationnel qu’elles avaient l’une surl’autre et de leur interdépendance.

Six mois plus tard, on observe une baisse de 40% de l’ab-sentéisme. On a aussi récupéré des heures de forma-tion. Les demandes de remplacement pour des périodesde 12 heures sont plus facilement satisfaites par du per-sonnel temporaire. Enfin, le personnel de l’unité a ex-primé une réelle satisfaction à propos de l’améliorationde son environnement de travail.

Gestion double au niveau du département Par Josef Smolen, Gerda Sailer et Wilhelm Strmsek

Un schéma de gestion bicéphale, harmonieux et coor-donné avec d’autres centres opérationnels apparaît es-sentiel pour le bien du soin au patient, la satisfaction et lasécurité du patient ainsi que pour la réussite économique.

Dans le domaine de la gestion double (médecin et infir-mière) au niveau du département, l’importance de la di-mension rentabilité en gestion est en augmentation, ain-si que les «soft skills», comme la compétence sociale etla résolution de conflits. Rien de très nouveau, encorequ’une coopération optimale des groupes profession-nels médicaux, particulièrement des médecins et des in-firmières, soit indispensable.

Dans le secteur hospitalier viennois, des structures etguidances générales ont été récemment mises en placepour effectuer de façon efficace des activités partagéesentre la médecine et les soins infirmiers. Ce cadre vise àdévelopper et redéfinir la qualité des services médicauxet infirmiers, ainsi que les formes de coopération entregroupes professionnels.


E X E C U T I V E S U M M A R I E S - F R A N C A I S




Devrions-nous acheter un système de gestion oncologique? Par Andrew Hoole et Edwin Claridge

La sélection et l’intégration de systèmes d’informationappropriés est un des défis qui attendent les gestionnaireshospitaliers dans leur quête d’établissements offrant unniveau élevé de soins cliniques, combiné à une efficienceet une bonne gouvernance financière et clinique. Ces ques-tions se compliquent particulièrement quand des systèmesdirectifs (top down), comme les SIH et les PACS sont enconflit avec des systèmes départementaux établis.

Un OMS (Oncology Management System) est devenu unélément essentiel du fonctionnement journalier des dé-partements oncologiques et une source de données po-tentiellement riche pour la gestion d’objectifs plus larges.Actuellement, par exemple, le niveau d’intégration pourl’assimilation d’éléments de l’OMS dans le SIH ou le PACSn’est pas complètement développé. Les normes de défi-nitions nécessaires à l’échange de données nationales etinternationales n’ont pas encore été approuvées. Il estnécessaire d’envisager ces questions lors de l’achat d’unesolution OMS et d’engager une discussion active autourdes relations futures entre OMS, SIH et PACS.

Focus: Lituanie

Ces cinq dernières années, la Lituanie a connu une descroissances économiques les plus fortes des états mem-bres de l’UE, avec 10,2% en 2003 et 8,9% en 2007.

Le système de soins de santé lituanien est conçu selonles principes de base communs à toutes les cultures eu-ropéennes. L’accès universel aux services médicaux debase est fourni à toute la population. Ces services sontle plus souvent gratuits pour le consommateur et financésselon un modèle d’assurance-santé obligatoire basé surla solidarité et opérationnel depuis 1997.

Depuis le 1er janvier de cette année des contributionsspéciales de santé à hauteur de 6% remplacent les allo-cations prélevées sur les impôts. Ces changements sig-nifient qu’environ 75% de l’assurance-santé obligatoireseront générés par les contributions d’assurance-santé(HIC) et 25% par le budget de l’état et d’autres sourcesd’importance marginale.

L’augmentation relative de l’importance du HIC signifieque le système se rapproche du modèle Bismarck, mêmesi certaines différences demeurent.

Même si on prend en compte que le tiers payant basé surle tarif de référence est courant pour les médicaments etautres produits médicaux, la limitation de ce tiers payantdébouche sur une absence virtuelle de formes complé-mentaires d’assurance-santé. A l’automne 2008 le gou-vernement a opté pour l’adoption nationale de comptesd’épargne médicaux (medical savings accounts) soutenuspar des avantages fiscaux, mais pour l’instant cette dé-cision n’est encore qu’une déclaration politique.

En 2003 le gouvernement lituanien a adopté une résolu-tion sur la stratégie de restructuration des établissementsde santé. Deux phases ont été prévues à cet effet, la pre-mière de 2003 à 2005, et la seconde de 2006 à 2008.

Pendant le processus de restructuration, des unités spé-cialisées ont été fermées dans de nombreux hôpitaux mu-nicipaux et locaux et transférées dans des hôpitaux ré-gionaux et universitaires.

En conséquence, le pays comptait 104 hôpitaux (à statutlégal) fin 2006. Comparé à 2000, le nombre d’établisse-ments a été réduit de 44%. Le taux d’hospitalisation a bais-sé progressivement entre 2000 et 2007 pour atteindre20,2 lits pour 100 habitants, une réduction de plus de 10%.

Durant la même période, la durée moyenne de séjour aété réduite de 2,2 jours.

Dans le cadre des objectifs et tâches requis pour la se -conde phase de la restructuration du secteur hospitalerrésidentiel, des plans sont conçus pour faciliter l’infra-structure de consultation externe et de départementsd’urgence et pour développer les services de revalidationexternes, d’hôpital de jour et de chirurgie ambulatoire.

L’association des directeurs d’hôpitaux lituaniens a étécréée en 1991. En 2004 l’association a évolué : elle a ac-tualisé sa charte, s’est structurée en association en tantqu’entité juridique en ce qui concerne les directeurs, cadressupérieurs et membres honoraires. En 1996, pendant lecongrès de l’AEDH à Tampere (Finlande), notre associa-tion a été acceptée en tant que membre de l’Associationeuropéenne des Directeurs d’Hôpitaux. L’association apour mission d’unir ses membres pour des actions com-munes, de les rassembler autour de questions allant del’amélioration de la performance des établissements desanté et de la qualité des services de santé, à l’améliora-tion de leur organisation et à la conception de la politiquede santé en collaboration avec les instances officielles,ainsi qu’à la participation à des activités organisées pardes institutions internationales.

> E X E C U T I V E S U M M A R I E S - F R A N C A I S




43

Das Gesundheitswesen in Frankreichist, wie bei den europäischen Nach-barn, seit mehreren Jahren mit erhe-blichen Probleme konfrontiert. Dieseäußern sich zwar in verschiedenenFormen, haben aber alle dieselben Ur-sprünge: Verknappung medizinisch-er Human ressourcen, starker Anstiegder Gesund heitskosten - gepaart miterheblicher Haushaltsmittelverknap-pung, Schwierig keiten, die notwendi-ge Bürgernähe von Einrichtungen desGe sundheitswesens mit der Ver-sorgungs sicherheit in Einklang zu brin-gen. Das alles führte zu einer Konzen-tration von Behandlung szentren undzu Technologiezentrum. Nach seinerWahl zum Präsidenten der Republik,kündigte Nicolas Sarkozy eine Neuor-ganisation für das französischeGesundheitswesen an. Parallel mit ein-er umfassenden Konsultation wurdeden Krankenhäusern der Gesetzes entwurfKrankenhaus-Patienten-Ges und heit-Region vorgelegt.

Inspiriert durch Erfahrungen, welche inEuropa in den letzten Jahren umge-setzt wurden, wird der Gesetz esent wurfim ersten Halbjahr 2009 vom franzö-sischen Parlament geprüft und solltefolgende Entwickl ungen enthalten:

In erster Linie bemüht sich derGesetzesentwurf um eine Neudef -inition des Begriffes des öffentlichenDienstes in Krankenhäusern. Es sollenjene Auf gaben präzisiert werden, dievon den Gesundheitseinrichtungen

wahrgenommen werden – unabhängig,ob sie öffentlich oder privat sind. DasZiel der Regierung ist es, sich allenBelastungen und Grenzen dieser Auf -gaben des öffentlichen Dienstes anzu -nehmen, um damit eine höhere Effiz -ienz des Sys tems zu gewährleisten.

Die anderen Innovationen sind dieEinführung des Begriffs "Gesund -heitsgebiet" und die Schaffung vonGebietsverwaltungen von Kranken -häusern, mit fester Struktur für dieZusammenarbeit zwischen öffen -tlich en Einrichtungen im selbenGebiet. Jedoch behalten alle gle-ichzeitig ihre rechtliche Unab -hängigkeit. Den Betrieben der selbenZone werden Anreize zur Schaf f unggemeinsamer Strategien geliefert,um Humanressourcen zu teilen, ihretechnischen Einrichtungen an einemOrt zu konzentrieren...

Parallel zu dieser territorialen Aus -richtung werden ab Januar 2010regionale Gesundheitsagenturen inKraft treten. Diese werden mit mehrAufgaben und Befugnissen ausges-tattet als die bestehenden regionalenKrankenhausagenturen. Die Agenturensind für die Festlegung und Um -setzung der Gesundheitspolitik einerRegion zuständig, welche die Krank -enhaus- und Gesundheitspolitik, dieambulanten Versorgung oder diemedizinisch-soziale Politik umfasst.Seit vielen Jahren entwickeln dieseAgenturen im Bereich des Kranken -

hauswesens und auch außerhalb ihreZusam menarbeit weiter.

Schließlich wird das neue Gesetz zuInnovationen beim internen Man -agement von Gesundheitsein richt -ungen führen: tiefgreifender Wandelder Entscheidungsträger in den Krank - en häusern, Stärkung der Befug nissedes Direktors, Stärkung der Rolle dermedizinischen Ge schäft s bereiche undihrer Zuständ igkeiten, aber auch neueFormen von Arbeits verträgen zurVerbes serung der Attraktivität beru-flicher Lauf bahnen in Krankenhäusernund insbesondere die Verknüpfungder Vergütung mit der Leistung ein -zelner Akteure.

In diesem Kontext des Umbruchs istes für die einzelnen Entscheid -ungsträger mehr als wichtig, zubeobachten, welche MaßnahmenKrankenhäuser in anderen Staatenzur Bewältigung der gleichen Pro b -lemen entwickeln. Das ist der Grund,weshalb die EVKD 2009 ihr Engage -ment auf der Suche nach Konverg -enz zwischen den Akte uren im Krank -en hauswesen in Europa verstärkenwird. Schritt für Schritt soll so einEuropa mit einem starken undkohärenten Gesund heitssystem auf -gebaut werden.

Gutes Neues Jahr 2009!

Paul CastelEVKD-Präsident


DER WANDEL IM GESUNDHEITSSYSTEM IN FRANKREICHPaul Castel

Leitartikel in (E)Hospital werden von Führungs persönlichkeiten der EVKD verfasst. Die hier veröffent lichten Beiträge gebendennoch ausschließlich die Meinung der Autoren wieder und sind nicht als offizielle Stel lung nahme der EVKD zu werten.

E K V D - D E U T S C H>



44

Vergangenes Jahr beschloss unseredänische Schwester-Organisation, dasdänische ,,Selskab For Ledelse I Sund-hedsvæsenet“, ein internationales Sub-Komitee zu gründen. Das Ziel ist ein Er-fahrungs- und Wissensaustausch mitder internationalen Gemeinschaft, dasVerfolgen von internationalen En-twicklungen im Managementbereichdes Gesundheitswesens und das Ein-bringen dänischer Erfahrungen im in-ternationalen Kontext (siehe dazu(E)Hospital 2008/5).

Als Startsignal dazu reiste eine dänischeDelegation mit 14 Teilnehmern vergan-genen Dezember nach Brüssel, um ver-schiedene Besuche zu absolvieren. Aufdem Programm stand unter anderem ein

Besuch im EU-Parlament bei der dänis-chen Europaabgeordneten Karin Rii-Jor-gensen und ein Treffen mit der Eu-ropäischen Kommission. Und es gab auchein Treffen mit der Ständigen VertretungDänemarks in Brüssel und vor allem mitden dänischen Regionalbüros.

Die EVKD begrüßte die Delegation -verbunden mit einem Besuch in derKlinik Saint-Jean – in ihren Büroräum-lichk eiten im genannten Krankenhaus.Der Gruppe wurden nicht nur die Aktiv-itäten der Organisation nähergebracht,sondern auch die derzeit wichtigstenPolitiken auf der europäischen Agen-da. Der Entwurf der Richtlinie über Pa-tientenrechte und grenzüberschreitendePflegeversorgung bot die Mög lich keit

über die Pflegequalität zu diskutieren.In diesem Zusammenhang wurde, wiebeim EVKD-Seminar 2007, auch disku-tiert, dass ein Akkreditierungsmodell zumehr Qualität führen kann. Das Themader Privatisierung und der Koexistenzvon öffentlichen und privaten Stake-holdern in der europäischen Kranken-hausszene stand auf der Agenda desGesundheitswesens ganz oben. Dieswird auch beim das Hauptthema desEVKD-Seminars in diesem Jahr sein(siehe Tagesordnung). Dänische undeuropäische Visionen über Kranken-hausführung wurden, im Licht der let-zten Bankenkrise und stürmischenBeziehung zwischen Krankenhausman-agement und Bereitstellern, währenddes Treffens ausgetauscht.

> NACHR I CH T EN D ER E UROPÄ I SCH EN V ER E I N I GUNG D ER KRANKENHAUSD I R EKTOREN


DÄNISCHE DELEGATION BESUCHT BRÜSSEL




Ehealth investmentVon Alexander Dobrev, TomJones und Karl A. Stroetmann

Die kürzlich fertiggestellte eHealth-Fi-nanzierungsstudie stellt einen allge-meinen Leitfaden für künftige Inve-storen im eHealth-Bereich dar undliefert eine Unterstützung bei Entschei-dungen über Finanzierungen. Derwichtigste Punkt der angebotenenModelle ist die Integrierung der In-vestitionsentscheidungen im eHealth-Bereich in die Gesundheitswesen-strategie der Organisation.

EHealth kann Ergebnisse liefern, aberes muss auch als Bestandteil des all-gemeinen Ressourcen betrachtet wer-den, die zur Bewältigung der Aufgabenbei der Gesundheitsfürsorge zur Ver-fügung stehen. Das Finanzier ungs -modell für die Investition sollte nur nacheiner wirtschaft lichen Analyse ausge-führt wird.

Die wichtigste Anforderung an die Di-rektoren, Führungskräfte und eHealth-Interessengruppen ist es, eHealth-In-vestitionen als einen integrierten Teilaller Investitionen zu behandeln. Vorallem Finanzführungskräfte und Man-ager haben hier eine spezifische Rolle.

Erstens sollte der Wert und die Aus -wirk ungen von eHealth erkannt wer-den, sodass die Finanzplanung er-weitert und entwickelt werden kann,um mit eHealth-Investitionen inner-halb über sehbarer Fristen arbeiten zukönnen. Zweitens müssen finanzielleManagementfähigkeiten entwickeltwerden, um Investitionen mit einembesseren Kosten-Nutzen Verhältniszu bekommen.

Rechtsaspekte von ICT in einem Krankenhaus Von Jean Herveg

EHealth bezieht sich auf die Anwendungvon Informations- und Kommunika-tionstechnologien im Gesundheitswe-sen. Es manifestiert sich durch eine bre-

ite Palette von Produkten und Dienst -leistungen für den Krankenhausbereich:

Von der Verwaltung elektronischer Pa-tientenakte oder Mitarbeiterdaten überden Einsatz von Video bzw. Behandlungmittels Video und bis hin zum Fernun-terricht für Teile des Personals. Ausrechtlicher Sicht sind diese Anwendun-gen häufig durch Verordnungen hin-sichtlich des Rechtes auf Achtung desPrivatlebens und dem Umgang mit per-sonenbezogenen Daten geregelt.

Aber auch andere Regelungen mussenbetrachtet werden, je nach Betrach-tungswinkel und Ansatz der Analyse.Diese beziehen sich auch auf Geräte,Gesetze betreffend Dienstleistungen,dem Krankenhaus-Haftungsrecht undWettbewerbsregeln. Ein Großteil dieserRegeln und Vorschriften ist nicht spez-ifisch für den Krankenhausbereich oderfür das Gesundheitswesen.

Patientensicherheit und eHealthVon Susan Burnett

Bei der Verbesserung der Patienten-sicherheit ist es wichtig, sich ein Bild vomWert der Systeme zu machen - hin-sichtlich Prävention, Analyse und derFähigkeit aus Fehlern zu lernen sowiedem Verständnis, dass menschlichesVerhalten ein Teil des Systems ist, in demLeute arbeiten.

In jeder Gesundheitsorganisation sollte beiStrategien bezüglich Informationstech-nologien großer Wert auf Patienten-sicherheit gelegt werden. Und diese solltebei den Systemen, die mit Technologie undPatientenversorgung verk nüpft sind, vonzentraler Bedeutung zu sein.

Zum Beispiel tauchen in der Personal-abteilung diverse Fragen auf - bezüglichPersonalausstattung und Zusammen -setz ung der Fähigkeiten zur Nutzung derneuen Systeme, Strategien über denEinsatz von Bediensteten auf Zeit, diemöglicherweise nicht ausreichend aus-gebildet sind, um die Anwendungen zu

nutzen; aber auch die Weiterbildung undBefähigung für sowohl neue, als auchvorhandene Mitarbeiter bei der Nutzungder Technologie.

Viele Organisationen haben beispiel-sweise neue Klauseln in Arbeitsverträgengegen den Missbrauch von IT eingeführt.

EHealth hat das Potenzial zu signifikan-ten Verbesserungen der Patienten-sicherheit, aber bringt auch neue Risikenmit sich. Krankenhausleitungen müssenein Verständnis für die Theorie der men-schlichen Fehler und Systemen habenund sicherstellen, dass sie über die er-forderlichen Management-Systeme ver-fügen, damit umzugehen.

ForumclinicVon I. Grau, J. Gene-Badia, E. Sanchez Freire, M. Bernardound M. DeSemir

Forumclinic besteht aus einer Reihe vonaudiovisuellen Materialien (DVDs und Web-site) in Spanisch und Katalanisch, dass imJanuar 2007 mit dem Ziel der Verbesserungder Lebensqualität von chronisch krankenPatienten gestartet wurde.

Basierend auf der Annahme, dass Pa-tienten durch ein besseres Verständnisihrer Krankheit autonomer werden,bezieht das Projekt die Patienten in dieklinische Entscheidungsfindung mit ein.Daher wurden Monographien zu is-chemischen Kardiografie, Diabetes, chro-nische obstruktive Lungen-Krankheit,Schizophrenie, Brustkrebs, Depressionund Faktoren von Herz-Kreislauf-Risikoverfolgständigt.

Das Portal verbindet Inhalte von allge-meinen Interesse in einem Text- und Mul-timedia-Format. Der Herausgeber-Blogbietet eine unmittelbare Zwei-Wege-Interaktion mit der Öffentlichkeit. VierArten von Informationen werden bere-itgestellt: Basisdaten zu jeder einzelnenKrankheit, jüngste Nachrichten imZusammenhang mit der Krankheit,Videos und 3D-Animationen und pro-fessionell moderierte Diskussionsforen.




E X E C U T I V E S U M M A R I E S - D E U T S C H>

Konfrontiert mit immerweniger Personal imGesund heitswesenVon Bruno Marchal

In den vergangenen zehn Jahren habenmehrere europäische Länder politischeMaßnahmen getroffen – das Ziel: Die Er-höhung des Zustroms in paramedizinischeBerufe und die Erhaltung bestehender Kad-er, die Aquirierung von Kran k en schwesternaus anderen Ländern, bessere Vergü-tungssysteme und die Einführung von flex-ibleren Arbeitsbedingungen.

Weit weniger wurde darüber geschrieben,wie Manager im Gesundheitswesen Prak-tiken zur Gewinnung und Erhaltung vonPersonal entwickeln können – die überbessere finanzielle Anreize und das Rekru-tieren von Krankenhauspersonal aus demSüden hinausgeht.

Im Wesentlichen besteht ein wirkung -svolles Management aus einem sichergänzendenden Bündel von HRM-Prak-tiken. Pfeffer identifiziert sieben wesen -tliche Elemente:

selektive Einstellung,Sicherheit der Beschäftigung,vergleichsweise hohe Entschädigung abhängig von der organisator ischen LeistungAus-und Weiterbildung - smöglichkeitenselbstgeleitete Teams und Dezentralisierung,Verringerung der Status-Unterschiede, und Austausch von Informationen.

Die Auswirkungen von Auslagerungen auf dasKrankenhauspersonalVon Thilo Ullrich

Aus verschiedenen Gründen macht esoft mehr Sinn, bestimmte Krankenhaus-Funktionen nach außen zu verlagern,als diese Aufgaben durch das Kranken-haus auszuüben.

Solche Gründe sind: eine größere Flexi-bilität; die Fähigkeit professionelles Know-how hinzuzuziehen, die Wirkung von Syn-ergien und Kooperationen oder dieAnnahme anderer Ausgleichssysteme.

Unabhängig der gewählten Methode,wird die Auslagerung von Dienstleistun-gen bzw. Teilen davon, Unternehmen injedem Fall eine höhere Reihe vonBeschäftigungs- und Arbeitsrechtsfra-gen bringen, einschließlich Bereiche derÜbertragung von Geschäfts- und Mitbe -stimmungsrechte der Arbeitnehmer inVertretungsorganisationen, d.h. Be-triebsrat oder Personalrat.

Um festzustellen, welche Rechte deneinzelnen Arbeitnehmer gewährt wer-den, ist es wichtig zu entscheiden, obein Auslagerungs-Vorschlag zu einerÜbertragung von Unternehmensre -chten führt.

Darüber hinaus müssen auch die Rechtedes Betriebs- oder Personalrates mit-betrachtet werden, um zu verhindern,dass zeitliche Verzögerungen oderkostenintensive Ansprüche entstehen.

Änderung der Arbeitszeit des Pflegepersonals in deronkologischen ChirurgieVon Anne-Marie Teller und Pascale Witz

Die Betreuung schwerer Fälle hat auchfür das Personal schwere körperliche undpsychische Folgen.

Das Pflegmanagement hat - im Ein-vernehmen mit der Geschäftsführung undder Abteilung für Humanressourcen - denMitarbeiter die Möglichkeit angeboten,anstelle einer 8-Stunden-Schi chten ineiner 12-Stunden-Schichten zu arbeiten.

Im Bewusstsein der Besonderheiten, diesich aus der Änderung des Zeitplansergeben, wurde der Wechsel auf frei-williger Basis, mit einer Evaluierung nachdrei und nach sechs Monaten, durchge-führt, um die beste Lösung zu finden.Eine sehr positive Resonanz kam von

Patienten, die "ihre" Krankenschwesteram ersten Tag bzw. innerhalb der erstenbeiden Tage kennenlernten.

Die Arbeitsatmosphäre änderte sich:verschiedene Vorkommnisse machtendie organisatorischen Auswirkungenuntereinander und deren Zusammen-hänge bewusst.

Sechs Monate nach dem Wechsel, er-folgte eine 40prozentiger Rückgang derFehlzeiten aufgrund von Erkrankungen.Stunden, die für die Aus- und Weiterbil-dung zur Verfügung standen, wurdenwieder zurückgefordert.

Anfragen für Transfers auf andereAbteilungen haben sich stabilisiert. UndForderungen nach Ersatz für die 12-Stunden-Schichten wurden, wenn not -wendig, von registrierten Kranken-schwestern leichter ersetzt.

Und vor allem haben die Mitarbeiter selb-st ihre Zufriedenheit über die Verb -esserung ihrer Arbeitsumgebung zumAusdruck gebracht.

Dual-Management auf AbteilungsebeneVon Josef Smolen,Gerda Sailer und Wilhelm Strmsek

Ein harmonisches und koordiniertesDual-Managementsystem in Zusam-menwirken mit anderen operativen Zen-tren erscheint für den Vorteil der Patien-tenpflege, -sicherheit und –zufrie denheit,sowie für den wirtschaftlichen Erfolg vongrößter Bedeutung.

Im Bereich des Dual-Management aufAbteilungsebene (Arzt und Kranken-schwester) ist die Bedeutung der Ren -tabilität auf dem Vormarsch, ebenso wiedie "soft skills" wie soziale Kompetenzund Konfliktlösung.

Hier gibt es nichts Neues, jedoch ist dieoptimale Zusammenarbeit zwischenden medizinischen Berufsgruppen, vorallem zwischen Krankenschwestern undÄrzten, unverzichtbar.




47

E X E C U T I V E S U M M A R I E S - D E U T S C H


E X E C U T I V E S U M M A R I E S - D E U T S C H

Im Wiener Krankenhausbetrieb wurdenkürzlich Strukturen, Rahmenbedingun-gen und Leitlinien eingeführt, umgemein same Aktivitäten zwischen medi-zinischen Personal und Pflegebereichwirksam umzusetzen.

Der Rahmen für den Medizin- und Pflege-bereich zielt auf die weitere Entwicklungund die Neudefinition der Qualität dermedizinischen Dienste und Pflegedien-ste ab, sowie auf die Form der Zusam-menarbeit zwischen den Berufsgruppen.

Sollten wir ein Onkologie-Management-Systemkaufen? Von Andrew Hooleund Edwin Claridge

Die Auswahl und die Integration derentsprechenden IT-Systeme ist eine derHerausforderungen für Krankenhaus-Manager in ihrem Streben nach einerOrganisationen auf hohem Niveau derklinischen Versorgung, in Verbindung mitEffizienz und guter finanzieller und klin-ischer Governance .

Die Fragen werden vor allem dannschwierig, wenn "Top-down" Systeme,wie z.B. HER, HIS und PACS mit eta -blierten Systemen in Dienststellen inBerührung kommen.

Ein OMS (Onkologie-Management-System) ist zur Zeit eine kritische Kom-ponente im täglichen Betrieb derOnkologie und eine potentiell reicheDatenressource für die Verwaltung, umgrößere Ziele zu erreichen.

Derzeit ist der Integrationslevel für z.B. dieAnpassung von OMS-Elementen überR&V in HIS und/oder PACS noch nicht gän-zlich entwickelt. Die erforderlichen Stan-dards für die Definitionen des nationalenund internationalen Datenaustausch wur-den bis jetzt noch nicht abgestimmt. BeiAnkauf einer OMS-Lösung sollten diesePunkte beachtet werden. Es ist auchwesentlich, sich aktiv in die Debatte überdie zukünftige Bezie hungen zwischen OMS,HIS und PACS einzubringen.

Fokus: Litauen

Während der letzten fünf Jahre hatteLitauen innerhalb der EU-Kandidaten-und Mitgliedsländer die höchste wirt -schaft liche Wachstumsrate, die 2003 10,3Prozent und 2007 8,9 Prozent erreichte.

Das Gesundheitswesen in Litauen ist nachden allgemeinen Basis-Prinzipien der eu-ropäischen Kulturen aufgebaut. Der all-gemeine Zugang zur medizinsichenGrundversorgung ist für die gesamteBevölkerung garantiert. Diese Dienste sindfür die Konsumenten meist kostenfrei undhauptsächlich durch eine seit 1997 beste-hende gesetzliche Krankenversicherungfinanziert. Ab dem 1. Januar 2009 wird einbesonderer medizinischer Beitrag in Höheeiner Zuweisung von 6 % aus der allge-meinen Einkommensteuer ersetzen. DieÄnderung bedeutet, dass etwa 75% derEinnahmen der gesetzlichen Kranken-versicherung durch Beiträge der Kranken-versicherung (HIC) und 25% durch Bei -träge aus dem Staatshaushalt und ausanderen Quellen von untergeordneterBedeutung finanziert werden.

Die relative Zunahme der Bedeutung derHIC bedeutet, dass das System sich demBismarck Modell annähert, aber gewisseUnterschiede bestehen bleiben.

Trotz der Tatsache, dass auf Grundlagevon Referenzbeträgen Beiträge fürArzneimittel und andere medizinischeProdukte zu leisten sind, liefern dieBeiträge keine praktischen Ergebnissefür die Krankenversicherung.

Im Herbst 2008 wird die Regierung dienationale Umsetzung von medizinis-chen Sparkonten mit steuerlichen Sub-ventionen vorschlagen, aber dieseEntscheidung ist nach wie vor nur einepolitische Erklärung.

2003 hat die Regierung von Litauen eineResolution über die Strategie der Um-strukturierung von Einrichtungen desGesundheitswesens angenommen. ZweiZeitphasen waren für die Umstruktu -rierung der medizinischen Einrichtun-

gen vorgesehen: der erste Zeitraum von2003-2005 und der zweite von 2006-2008.

Während der Umstrukturierung wurdenspezialisierte Einheiten in vielen kommu-nalen und regionalen Krankenhäuserngeschlossen und Spezialaufgaben aufspezialisierte Abschnitte der Bezirks - undUniversitätskliniken verlagert.

So zählte das Land bis zum Ende desJahres 2006 nur 104 Krankenhäuser miteinem rechtlichen Status. Verglichen mit2000 fiel die Zahl der stationären Ein-richtungen um 44,4%.

Die Aufnahmen in den Krankenhäusern gin-gen von 2000 bis 2007 schrittweise zurückund erreichte 20,3 Betten pro 100 Einwohner,eine Senkung von mehr als 10%.

Im Rahmen der Ziele und Aufgaben, diein der zweiten Phase der Umstrukturierungdes stationären Bereichs erforderlichwaren, gab es Pläne zur Förderung der In-frastruktur der beratenden ambulantenEinrichtungen und

Der Verband der Krankenhaus-ManagerLitauens wurde 1991 gegründet. Im Jahr2004 entwickelte sich der Verein: seineCharta wurde geändert und ein Verbandals juristische Person gegründet, derenManager leitende Mitarbeiter im Gesund-heitswesen und Ehrenmitglieder sind.

1996, während des EVKD-Kongressesin Tampere (Finnland), wurde der Vere-in als Mitglied der Europäischen Vere-inigung der Krankenhaus-Manager an-erkannt.

Der Verein hat die Aufgabe, die Mitgliederfür die gemeinsamen Maßnahmen zuvereinen und in bestimmten Fragen zukoordinieren: der Neuordnung undVerbesserung der Leistungsfähigkeit derEinrichtungen des Gesundheitswesens,der Verbesserung der Qualität der medi-zinischen Versorgung, der Verbesserungihrer Organisation, der Gestaltung derGesundheitspolitik in Zusammenarbeitmit amtlichen Stellen oder der Teilnahmean Aktivitäten der internationalen Insti-tutionen und Organisationen.




November

> A G E N D A 2 0 0 9

ECR 2009 European Congress of Radiology, Villach, Austriawww.myesr.org/cms/website.php

International Forum on Quality and Safety in Healthcare,Berlin, Germanywww.internationalforum.bmj.com

Improving Care Through Patient Centered Environments, Dublin, Irelandwww.healthcare-ireland.com

Medetel, Luxembourgwww.medetel.lu

HIMSS Healthcare Information & Management Systems Society Annual Conference and Exhibition, Chicago, USAwww.himssconference.org

6th Annual World Health Care Congress, Washington, USAwww.worldcongress.com/events/HR09000

12th World Congress on Public Health, Istanbul, Turkeywww.worldpublichealth2009.org

52th Hospital Management Congress of the Upper Austrian Association of Hospital Managers, Linz, Austriawww.ovkd.at/ooe/kongress.htm

17th International Conference on Health Promoting Hospitals and Health Services (HPH) Hersonissos, Creta, Greecewww.univie.ac.at/hph/crete2009

5th Annual World Health Care Congress EuropeBrussels, Belgiumwww.worldcongress.com/events/HR09015/index.cfm?confCode=HR09015

IHM Annual Conference Management for Quality ImprovementLondon, UKwww.healthcare-events.co.uk

ECCMID, 19th European Congress of Clinical Microbiology and Infection Diseases, Helsinki, Finlandwww.congrex.ch/eccmid2009

European Congress on HealthInformation Systems, Paris, Francewww.health-it.fr

16 Congreso Nacional de Hospitales Extremadura 2009,Caceres, Spainwww.16congresohospitales.org

EAES 17th Congress of the EuropeanAssociation for Endoscopic Surgery,Prague, Czech Republic www.congresses.eaes-eur.org

MCC Health World 2009, Aachen, Germanywww.health-world.info

Top Clinica, Stuttgart, Germanycms.messe-stuttgart.de/cms/index.php?id=35437

NI2009 10th International Congress on Nursing Informatics,Helsinki, Finlandwww.ni2009.org

34th Multidisciplinary Congress of ESMO, the European Society for Medical Oncology, Berlin, Germanywww.esmo.org/events/berlin-2009-congress.html

11th European Health Forum «Creating a better future for health in Europe», Gastein, Austriawww.ehfg.org

Medica 2009, Düsseldorf, Germanywww.medica.de

EAHM Seminar «Towards a balanced cooperation of public and private actors», Düsseldorf, Germanywww.eahm.eu.org

48

Correspondents

AUSTRIA

Josef Hradsky - [email protected]

Eric Engelbrecht - [email protected]

Nina Muskurova- [email protected]

Mile Klepo - [email protected] Ivan Lukovnjak - [email protected]

Asger Hansen - [email protected] FINLAND

Alpo Rajaniemi - [email protected]

Michel Hédouin - [email protected]çois Godard - [email protected]

Rudolf Hartwig - [email protected] Kölking - [email protected] BRITAIN

Susan Hodgetts - [email protected]

George J. Stathis - [email protected]

Lajos Ari - [email protected] Kövesi - [email protected]

Björn Astmundsson - [email protected]

Ann Marie O’Grady - [email protected]

Dr Luigi d’Elia - [email protected]

Rimantas Sagidavicius - [email protected] Gendvilis - [email protected]

Jan Aghina - [email protected]

Erik Normann - [email protected]

Mieczyslaw Pasowicz - [email protected]

Manuel Delgado - [email protected]

Juraj Gemes - [email protected] SLOVENIA

Janez Remskar - [email protected] Turk - [email protected]

Mariano Guerrero - [email protected]

Christian Schär - [email protected]

Yasar Yildirim - [email protected]

European Association of Hospital ManagersEditorial SecretariatEMC Consulting GroupWetstraat 28/7B-1040 Brusselse-mail: [email protected]: www.myhospital.eu

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