The first trial of Health Impact Assessment on the management reform of a public hospital

The first trial of Health Impact Assessment on the management reform of a public hospital

Michiko Hoshiko, Kunio Hara, Tatsuya IshitakeKurume University School of Medicine, Japan

HIA2011 　 Ⅺ　 HIA International Conference, Granada (Spain) 　

The changes of Japanese hospital number

Public Others Private

Public hospitals Financialdifficulties ！

Public Hospital Transformation

Guidelines (2007)

Public Hospital Transformation

Guidelines (2007)

Finance ( 2006) Finance (2009)About30%

About70%

About40%

About60%

Public hospital Private hospital

Salary for employees 　 High (60% of profits) 　 Low (50% of profits)

Cost of medical materials 　 High (30% of profits) 　 Low (20% of profits)

Depreciation of equipment High (8% of profits) Low (5% of profits)

《 The difference of Public and Private 》

Public hospitals are in red rather than Private hospitals ！

Public hospital

Private hospital

Decision of budgets

city assemblythe director of

a hospital

Decision of purchase

city assembly the director of a hospital

Authority and

responsibility

a mayorthe director of

a hospital

Speed of decisions

slow quick

Status of employees

civic servantsnon-civic servantsBlue ; demerit red 　 ; merit

Classification of management transformation of public hospital

Independentposition

Low

High

Publicposition LowHigh

complete privatization

Local incorporated administrative system(non-civic servant )

Applied all of the provisions of the Local Public Enterprise Law (all application)

Local incorporated administrative system (civic servant )

Designated administrator system

Applied all of the provisions of the Local Public Enterprise Law ( a part application)

Management transformation

Aim

The aim of our study was to clarify the impact of Hospital A’s management transformation on the health of residents, patients, and hospital employees and to determine the priority order of health impact before management transformation.

Public Hospital

Local incorporated administrative system (non-civic servant )

～ 2009 2010 ～

Hospital A

Methods・ Concurrent and comprehensive HIA・ Period ; April 2009 – March 2010 (before management transformation)・ Steering group ; 17 members 4 hospital staff ( clerk, nurse, radiologist, examiner ) 2 administrative officials 2 healthcare specialists 2 labour union members 2 residents, 1 paramedic 1 physical therapist , 3 academic researchers

• Government policy analysis (specific information, from publicly available comments related to hospital management publications issued by hospitals )

• Community profiling (profiling of A city and B city)• Compilation of qualitative and quantitative data (questionnaires to hospital employees. Interview executives and leader of the labour union 　　 in Hospital A and Hospital B) • Health impact assessment positive and negative aspects separated certainty of evidence (high,medium,low) the degree of impact(large,medium,small)

Conduct assessment

Hospital B

Priority order of health impact

Degree 　　　 ofimpact

Certainty of impact (frequency)

large

medium

small

low medium high

Highest

priority

X

Y

Hospital A Hospital B The number of beds 350 470

The number of medical care units 18 27

The number of employees 405 686

Population of medical care 500,000 residents 690,000 residents

Transformation stylePublic 　　 Local incorporated administrative system (non-civic servant)

Public 　　 Local incorporated administrative system(non-civic servant)

start of managementtransformation April 2010 April 2008

method of management

transformation

bottom up methods (labour-management negotiations)

top down methods

The employees agree withhospital executives

The employees developed feelings of distrust toward

hospital executives

Result

Result

Target groups Positive impact

Negativeimpact

Residents, Patients ３３Specialists(nurses, technicians) ２１

Doctors ２０Hospital executives １３Hospital clerks １２Fire departments ０２Total 9 11

≪The number of HIA for target groups≫

Group Predictive health impact Direction

Certainty

Degree

Residents,　Patients

1.Non-public　 (private)　 system　 will　help the　

　　　 hospital　 improve　 its　 medical　services　and　

　　provide　a　high　level of　treatment　to　its　patients.　

P low large

2.　 The　 transformation　 will　 help　 the　hospital　　　　　 provide　 residents　 with　 higher quality　of　　　　　　　 obstetrics/emergency　 medical　treatment　　　　 (i.e.　 unprofitable　 medical　treatment).

Pmedium

large

3.　 By　 providing　 employees　 with　training,　　　　　 improving　 not　 only　 their　professional　skills　but　　　　　also　their　personality,　the　hospital　can　offer　a　　　　　 higher　 quality　 of　 services　 to　 its　residents.　

P low large

4.　 Concerns　 if　 the　 hospital　 will　continue　to　　　　　function　as　a　public　institution.

Nmedium　　　　–　low

large

5.　 Concerns　 about　 how　 the　 hospital　side　will　deal　　　　　 with　 medical　 negligence　 and　malpractice.

N lowmedium

6.　 Uncertainly　 about　 the　transformation,　because　　　　　 only　 a　 limited　 amount　 of　information　is　　　　　available　to　residents

N

　　　　medium　　　　　　–low

medium

Result


Certainty

Degree

　Specialists

7.　 Due　 to　 the　 change　 from　 a‘ten-patients-per-nurse’　 system　 to　　 a　‘seven-patients-per-nurse　 system’,　nurses　will　have　more　time　to　attend　seminars　 ,　 take　 batter　 care　 of　patients　and　avoid　overworking’　

P　　medium

medium

8.　 A　 series　 of　 seminars　 on　 the　transformation　 helped　 build　 a　 rust-based　 relationship　 between　employees　 and　 the　 hospital　　management　(director).

P lowmedium

9.　Concerns　about　changes　 in　salaries　and　 working　 conditions　 after　 the　hospital　 becomes　 a　 non-public institution.

N high large

　　　Doctors

10.　 Improving　 the　 treatment　 of　doctors　 (　 with　 an　 annual　 salary　system,　 motivating　 work　environment,　 stable　 staffing　 levels,　educational/research　 opportunities　and　immediate　purchases　of　required　equipment)　 will　 increase　 both　 their　willingness　 to　 work　 and　 their　emotional　fulfillment.

Pmedium　　　　-　low

medium

11.　 Because　 of　 the　 promotion　 of　 the　connection　　　between　the　City　Hospital　and　clinics　system,　　　more　 patients　 visit　 their　 local　 clinic　before　coming　　　into　the　City　Hospital.

P lowmedium


Certainty

Degree

　

Hospital　Executives

12.　 As　 a　 result　 of　 repeated　seminars　 held　 about　 the　transformation,　 the　 relationship　between　 the　 hospital　 executives　and　 other　 employees　 improved.　The　 expected　 result　 of　 this　ongoing　 consultation　 was　expected　to　help　employees　feel　a　sense　of　fulfillment　at　work　

P mediummedium

13.　 Concerns　 regarding　 procuring　sufficient　 numbers　 of　 nurses　 for　the　 implementation　 of　 a　 ‘seven-patients　-per-nurse’　system.　

N

high-mediu

m

medium

14.　 Frustration　 because　 concept　 of　a　 ‘local　 incorporated　administrative　 agency/non-civic　servant　style’　is　not　well-regarded　by　hospital　employees　in　general.　

N highmedium

15.　 Concerns　 about　 business　stability　post　transformation.　

N highmedium


Certainty

Degree

Hospital　　Clerks

16.　 As　 there　 will　 be　 no　 need　 for　 a　personnel　　　　　　 reshuffle　 after　 the　 hospital’s　transformation,　　　hospital　clerks　will　be　able　to　focus　on　their　　specialisations　and　will　be　satisfied　with　their　　　jobs.

P lowmedium

17.　 The　 business　 operation　transformation　may　

　　 cause　 stress　 among　 some　employees　because　

　　 of　 the　 differences　 in　 workload　between　

　　 dispatched　 workers　 (employees　sent　from　the　

　　 city　 government)　 and　 regular　employees　

　　 (employees　 directly　　 hired　 by　 the　hospital).　　

Nmedium

medium

18.　 Although　 the　 workload　 of　preparing　the　

　　 materials　 on　 business　transformation　has　

　　 decreased　 (as　 of　 October　 2009),　the　actual　　

　　 preparation　 work　 for　 the　transformation　has　

　　increased.

N highmedium

　FireDepartment　

　Staff

19.　 There　 is　 a　 possibility　 that　 the　hospital　may　

　　 not　 accept　 as　 many　 patients　 as　before.

Nmedium

large

20.　Concerns　regarding　whether　the　hospital　can　

　　 accept　patients　who　 fall　 ill　 on　 the　streets.

N low small

Priority order of HIA

≪positive impact ≫

≪negative impact≫

degreeof

impact

degreeof

impact

Certainly of impact (frequency)

small

medium

large

small

medium

large

low

Certainly of impact (frequency)

medium high mediumlow high

213

7 8 10 121116

AB

CDE

194 9

141518131765

20

AB

B

C

DEFG

H

Y Y

XX

Conclusions

Our study showed that the management transformation of public hospitals would affect residents and employees both positively and negatively.

The notable achievement of this study was that itencouraged the hospital to organise a series of labour-management discussion based on mutual trust in a democratic method rather than a top-down method.

The approach eventually intensified the bonds of the labour-management relationship and helped the hospitalmanagement maintain its credibility with its employees.

Thank you

Number.　　　　　　　　　　　　　　　Predictive　health　impact

Certainty　(high,　medium,　low）

Degree　 of　impact 　(large,　medium,　small）

9.　 Concerns　 about　 changes　 in　salaries　and　　　working　 conditions　 after　 the　hospital　　 becomes　 a　 non-public　institution.

high large

《 Specialists(nurses　and　technologists）》　Negative　effects

Priority order of HIA

≪positive impact ≫

≪negative impact≫

degreeof

impact

degreeof

impact

Certainly of the impact (frequency)

small

medium

large

small

medium

large

low

Certainly of the impact (frequency)

medium high mediumlow high

213

7 8 10 121116

AB

CDE

194 9

141518131765

20

AB

B

C

DEFG

H

R R R

C D S D E S

R F S

R R C E C E E

F

R ： residents/patients ， S ： specialists,　D： doctors,　M：hospital　executives,C ： hospital　clerk　staff， F ： fire　department

Y Y

X X

5. Health Impact assessment



Degree　of　impact 　(large,　medium,　small）

1.　　 Non-public　 (private)　 system　 will　help 　 the　　 hospital　 improve　 its　 medical　services　and　provide　　 a　 high　 level　 of　 treatment　 to　 its　patients.　

low large

2.　　 The　 transformation　 will　 help　 the　hospital　provide　　residents　with　higher　quality　of　　 obstetrics/emergency　 medical　treatment　　 (i.e.　 unprofitable　 medical　treatment).

medium large

3.　　 By　 providing　 employees　 with　training,　improving　　not　only　their　professional　skills　but　also　their　　personality,　the　hospital　can　offer　a　higher　　quality　of　services　to　its　residents.　

low large

《 Residents　,　Patients 　　　　》 Positive　effects

Our study showed that the management transformation of public hospitals would affect residents and employees both positively and negatively.

The notable achievement of this study was that itencouraged the hospital to organise a series of labour-management discussion based on mutual trust in a democratic manner rather than a top-down manner.

The approach eventually intensified the bonds of the labour-management relationship and helped the hospitalmanagement maintain its credibility with its employees.

Conclusions

Thank you

《　 Fire　department　staff 　　　》Negative　effects




19.　　 There　 is　 a　 possibility　 that　 the　hospital　　

　 may　 not　 accept　 as　 many　patients　as　

　before.

medium large

20.　　 Concerns　 regarding　 whether　the　hospital　

　can　accept　patients　who　fall　ill　on　the　

　streets.

low small




13.　Concerns　 regarding　 procuring　sufficient　

numbers　 of　 nurses　 for　 the　implementation　

of　 a　 ‘seven-patient-per-nurse　system’.　

　　　　　　　　　　　　　high　　　　-　　　　

medium

medium

14.　　Frustration　because　concept　of　a　‘local　　incorporated　administrative　　 agency/non-civic　 servant　 style’　is　not　　　 well-regarded　 by　 hospital　employees　in　　general.　

　　　　　　

　　　　　　　　high medium

15.　　 Concerns　 about　 business　stability　post　

　transformation.　

　　　　　　　　　high medium

《Hospital　Executives 　》Negative　effects





1.　　 Non-public　 (private)　 system　 will　help 　 the　　 hospital　 improve　 its　 medical　services　and　provide　　 a　 high　 level　 of　 treatment　 to　 its　patients.　

low large


medium large


low large






1.　　 Non-public　 system　 will　 help　 the　hospital　improve　　 its　 medical　 services　 and　 provide　 a　high　 level　 of　 treatment　 to　 its　patients.　

low large


medium large


low large


《 Residents　,　Patients 　　　　》Negative　effects




4.　　Concerns　if　the　hospital　will　continue　to　function　　as　a　public　institution.

　　medium　　　　　　-　　　　　low

large

5.　　 Concerns　 about　 how　 the　 hospital　side　will　deal　　　　 with　 medical　 negligence　 and　malpractice.

　　　　　　　　　　　low medium

6.　　 Uncertainty　 about　 the　transformation,　because　　only　a　limited　amount　of　information　is　available　to　　　　residents.

　　　　　　　medium　　　　　　　 -　　　　　　 low

medium

《 Specialists(nurses　and　technologists)　　》 Positive　effects




7.　　Due　 to　 the　change　 from　　a‘ten　patient-　per-nurse　system’　 to　a　 ‘seven-patient-　 per-nurse　 system’,　 nurses　 will　have　　　more　time　to　attend　seminars　,　take　better　　 care　 of　 patients　 and　 avoid　overworking.　

　　　　

medium　　　

medium

8.　　 A　 series　 of　 seminars　 on　 the　transformation　　 helped　 build　 a　 trust-based　relationship　　 between　 employees　 and　 the　hospital　　　　management　(director).

　　　　　　　　　　　　　　　　　　　　　　　　low medium

《 Doctors 》 Positive effects




10.　　 Improving　 the　 treatment　 of　doctors　(with　

　 an　 annual　 salary　 system,　motivating　work　

　 environment,　 stable　 staffing　levels,　

　 educational/research　opportunities　and　

　 immediate　 purchases　 of　required　

　 equipment)　 will　 increase　 both　their　

　 willingness　 to　 work　 and　 their　emotional　

　fulfillment.

　　　medium　　　　　　　-　　　　　low

medium

11.　　Because　of　the　promotion　of　the　　 connection　 between　 the　 City　Hospital　　　　 and　 clinics　 system,　 more　patients　visit　their　　　　 local　 clinic　 before　 coming　 into　the　City　　　　Hospital.

　　　　　　　　　　　　　　　　　　　　low medium

《Hospital　Executives 　》Positive　effects


Certainty　(high,　medium,　 low ）


12.　　 As　 a　 result　 of　 repeated　seminars　held　

　 about　 the　 transformation,　the　

　 relationship　 between　 the　hospital

　 executives　 and　 other　employees　

　 improved.　 The　 expected　result　of　this　

　 ongoing　 consultation　 was　expected　to　

　help　employees　feel　a　sense　of　

　fulfillment　at　work.　

Medium Medium

《Hospital　Clerks 　　　》Positive　effects




16.　　As　there　will　be　no　need　for　a　personnel　　　　reshuffle　after　the　hospital’s　　 transformation,　 hospital　clerks　will　be　　 able　 to　 focus　 on　 their　specialties　　 and　 will　 be　 satisfied　 with　their　jobs.

low medium




17.　　 The　 business　 operation　transformation　　　

　may　cause　stress　among　some　employees　

　 because　 of　 the　 differences　 in　workload　

　 between　 dispatched　 workers　(employees　

　sent　from　the　city　government)　and　

　 regular　 employees　 (employees　directly　　

　hired　by　the　hospital).　　

medium medium

18.　　 Although　 the　 workload　 of　preparing　the　　

　 materials　 on　 business　transformation　has　

　 decreased　 (as　 of　 October　2009),　the　

　actual　preparation　work　for　the　　transformation　has　increased.

high medium

《Hospital　Clerks 　　　》Negative　effects

Documents

The first trial of Health Impact Assessment on the management reform of a public hospital