2. Ethiopian Health Service Program and Regulations Learning objectives • At the end of this topic, the learner should be able to: – Understand the Ethiopian health policy – Describe health service program of the country – Identify health care system regulations – Explain health information system policies and procedures 1 Ethiopian health policy • Policy: The set of basic principles and associated guidelines, formulated and enforced by the governing body of an organization, to direct and limit its actions in pursuit of long-term goals (management definition). • Health Policies: According to world health organization (WHO), health policy is defined as decisions, plans, and actions that are undertaken to achieve specific health care goals within a society. 2 Ethiopian health policy… • An explicit health policy can achieve several things:– Defining a vision for the future which in turn helps to establish targets and points of reference for the short and medium term. – Outlining priorities and the expected roles of different groups. – Building consensus and inform people. 3 Ethiopian health policy… • Strategies: a method or plan chosen to bring about a desired future, such as achievement of a goal or solution to a problem. • Regulation: a legal provision that creates, limits, or constrains a right, creates or limits a duty, or allocates a responsibility. • Guideline: is a statement by which to determine a course of action. – aims to streamline particular processes according to a set routine or sound practice. – may be issued by and used by any organization (governmental or private) to make the actions of its employees or divisions more predictable, and of higher quality actions. 4 Ethiopian health policy… • Rule: Rule and ruling usually refers to standards for activities. • Procedure: is a document written to support a policy. – It is designed to describe Who, What, Where, When, and Why by means of establishing organization accountability in support of the implementation of a policy. 5 Ethiopian health policy… • Following the change of government in 1991(G.C), a number of political and socioeconomic reform measures were put in place. 1. the development and introduction of a new National Health Policy in 1993 2. and, in 1997, the formulation of a comprehensive rolling 20-year Health Sector Development Plan (HSDP). 6 The National Health Policy • The Government of Ethiopia formulated the National Health Policy in 1993. • The policy emanated from commitment to democracy and gives strong emphasis to the fulfilment of the needs of the less privileged rural population that constitutes about 85% of the total population in Ethiopia. 7 The National Health Policy Policy linkages MDGs GTP HSDP is the Health main Policy vehicle 8 Ethiopian health policy… • The 1993 policy principally focuses on fiscal and political decentralization, expanding the PHC services to all segments of the population and encouraging partnerships and the participation of nongovernmental actors. 9 Ethiopian health policy… General theme of the policy • Democratization and decentralization of the health system; • Prevention of disease and Promotion health • Ensuring accessibility of health care to all population; • Promoting inter-sectoral collaboration • Promoting and enhancing national self- reliance in health by mobilizing and efficiently utilizing internal and external resources. • The health policy has also identified the priority intervention areas and strategies to be employed to achieve the health policy issues. 10 Ethiopian health policy… • Assurance of accessibility of health care for all segments of the population. • Working closely with neighboring countries, regional and international organizations to share information and strengthen collaboration in all activities contributory to health development including the control of factors detrimental to health. • Development of appropriate capacity building based on assessed needs. 11 Ethiopian health policy… • Provision of health care for the population on a scheme of payment according to ability with special assistance mechanisms for those who cannot afford to pay. • Promotion of the participation of the private sector and nongovernmental organizations in health care. • Many of the national policies like: the Policy of population, Women, Prevention and Control of HIV/AIDS, Drug including the national health policies are congruent to other Macro level policies like the growth and transformation plan (GTP) and the Agriculture led rural development strategy. 12 Ethiopian health policy… Facts Considered during Ethiopian Health Policy Development • Life expectancy at birth is estimated 53 years due to very high premature mortality. • Despite this, the population is expected to double in the next two decades leading to considerable pressure on social services including health. • Parasitic and infectious diseases account for high mortality and morbidity. • Health of children and mothers are affected by harmful traditional practices besides diseases. 13 Ethiopian health policy… • Malnutrition is prevalent particularly among children and mothers. • While workers in different production sectors are exposed to accident and illness due to the nature of their occupation, efforts to establish occupational health standards and services are very minimal. • Environmental health problems attribute to the occurrence of the great proportion of communicable diseases in the country. • The access to safe and adequate water supply is far below the needs of the population. 14 Ethiopian health policy… • The bulk of the people lack adequate sanitary facilities. • The method used to dispose human excreta poses a threat to public health. • Modern health care delivery systems are inadequate and remote to the wider population and characterized by ineffective organization, poor logistics and technological support and infrastructure. • Access to modern pharmaceutics is very limited. • Indigenous health technologies have been widely used in Ethiopia. • The development of health in a country needs to be supported by the development of Health Science and Technology (HST 15 Ethiopian health policy… • HST encompasses the scientific capability to undertake studies in relevant fields such as Biomedical, Public Health, Pharmaceutical, Clinical and Traditional Medicine. • Moreover, the small number of health activities has been uncoordinated resulting in unnecessary duplication of efforts and wastage of insufficient resources. • HST undertakings suffer from lack of adequate infrastructure, limited access to scientific and technological information and shortage of trained manpower. • The negative effects of these problems are augmented by inadequate funding and incentives as well as absence of career development structure in HST institutions. 16 Health Service Development Program • HSDP is considered as a policy implementation strategic document that guides the development of sub national plans and sets the rule of engagement in the health sector. • It responds to a number of problems identified in the health service coverage and quality, and some of the major objectives of the HSDP –I, II and III were: 17 Health strategies/plans Health strategies/plans 1. HSDP I – Covered the first five years (1997/98–2001/02) – Prioritized disease prevention – Introduced a four-tier system for health service delivery – Characterized by a primary health care unit (PHCU), comprising one health center and five satellite health posts; the district hospital, zonal hospital and specialized hospital. 18 Health strategies/plans… 2. HSDP-II (2002/03–2004/05) – Introduced the Health Service Extension Program – Innovative health service delivery system – It is a community based health care delivery system provided at kebele and household levels with focus on sustained preventive health actions and increased health awareness. 19 Health strategies/plans… 3. HSDP III (2005/6 - 2009/10) – Directly aligned with the health-related MDGs – Focuses on high-impact health system strengthening interventions needed to accelerate scale-up and increase coverage of key health services for HIV, TB, malaria, as well as maternal and child health. 20 Health strategies/plans… 4. HSDP IV (2010 – 2015) – Developed as part of the National GTP – Renewed commitment to the achievement of MDGS – Gives priority to maternal and child health, nutrition, as well as the prevention and control of major communicable diseases, such as HIV/AIDS. – Emphasizes the strengthening HEP to improve the quality of PHC, HRD and health infrastructure. – Developed the three tier health delivery system 21 Health strategies/plans… • Increase access and coverage to health care, along with utilization • Improve service quality through training and an improved supply of necessary inputs • Strengthen management of health services at Federal and Regional levels 22 Health strategies/plans… • key components of the method used to develop the HSDP IV : 1. Policy framework 2. Health sector strategic assessment – Strategy of HSDP – Strategic Objectives –Performance Measures and Strategic initiatives of HSDP IV 3. Costing & Financing of HSDP-IV 23 Health strategies/plans… 1. Policy framework • The Ethiopian health sector has set objectives for the effective health interventions with the aim of reaching every section of population and meeting the health related MDG & targets 24 Health strategies/plans… • The development of HSDP IV has taken into account certain National health policy and other national health related policies :– policy for HIV/AIDs prevention and control, – national drug policy, – population policy, – national policy on women, – national development and transformation plan and – rural development policy and strategies 25 Health strategies/plans… ◊ international commitments like the MDG goals and targets ◊ MDG 4, 5 and 6 are particularly falling under the domain of the health sector. ◊ Each goal will be achieved through predetermined targets. 26 MDGs MDG 1: Eradicate extreme poverty and hunger MDG 2: Achieve universal primary education MDG 3: Promote gender equality and empower women MDG 4: Reduce child mortality MDG 5: Improve maternal health MDG 6: Combat HIV/AIDS, malaria and other diseases MDG 7: Ensure environmental sustainability MDG 8: Develop a global partnership for development 27 Targets for health related MDG Target1. Halve, between 1990 and 2015, the proportion of people whose income is less than one dollar a day. Target 2. Halve, between 1990 and 2015, the proportion of people who suffer from Hunger Target 4. Eliminate gender disparity in primary and secondary education Target5. Reduce by two thirds, between 1990 and 2015, the under-five mortality rate Target 6. Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio. Target 7. Have halted by 2015 and begun to reverse the spread of HIV/AIDS. 28 Targets for health related MDG Target 8. Have halted by 2015 and begun to reverse the incidence of malaria and other major diseases. Target 9. Integrate the principles of sustainable development into country policies and programs and reverse the loss of environmental resources. Target 10. Halve by 2015 the proportion of people without sustainable access to safe drinking water. Target 18. In cooperation with the private sector, make available the benefits of new technologies, especially information and communications. 29 Health strategies/plans… 2. Health sector strategic assessment • Health sector organizations were assessed to have clear picture on the power and duties of each organization in the health sector. • Mandates are formally defined in the Ethiopian laws and regulations for public organizations such as the FMOH and RHB by the legislative body. 30 Health strategies/plans… Role of Federal ministry of Health: Initiate policies and laws, prepare plans and budget, and implement upon approval Establishing and administering referral hospitals as well as study and research centers. Determining the qualifications of professionals required to be engaged in public health services at various levels 31 Roles cont’d … Undertaking the necessary quarantine control to protect public health. Determining standards to be maintained by health services. Devising strategies, means and ways for the implementation of prevention, control and eradication of communicable diseases 32 Health strategies/plans… Role of Regional health bureau: Prepare, on the basis of the health policy of the country, the health care plan and program for the people of the region, and to implement same when approved. Organize and administer hospitals, research and training institutions that are established by the regional government. 33 Health strategies/plans… Issue license to health centers, clinics, laboratories and pharmacies to be established by NGOs and private investors and supervise Cause the provision of vaccinations, and take other measures, to prevent and eradicate communicable diseases. 34 Health strategies/plans… Participate in quarantine control for the protection of public health. Ascertain the nutritional value of foods. 35 Health strategies/plans… Role of woreda health office: Manage and coordinate the operation of the primary health care services at woreda levels. Providing political leadership for health. Ensuring the community’s demand for health care is properly addressed. Planning, resource mobilization and allocation, monitoring and evaluation of health programs and the delivery of health services. 36 Health strategies/plans… Facilitating inter-sectoral collaboration. Provide guidance to enhance the partnership with NGOs, CSOs and private sector. Regional, zonal and district administrative council will play crucial roles in the implementation of HSDP IV. 37 Health strategies/plans… • The other outcomes of the assessment of the health sector are identifying its mission and visions. The mission of FMOH: – to reduce morbidity, mortality and disability and improve the health status of the Ethiopian people through providing and regulating a comprehensive package of promotive, preventive, curative and rehabilitative health services via a decentralized and democratized health system. 38 Vision of FMOH:– To see healthy, productive and prosperous Ethiopian Core values:– community first (customer), commitment, change, collaboration, trust and continued professional development as of any health 39 Health strategies/plans… • The Strategy HSDP IV has three key elements:– Customer’s core values, – strategic themes and prospective. – The customer value proposition • The strategic themes are key areas in which the health sector must excel in order to achieve its mission and vision. 40 Health strategies/plans… • These strategic themes are: – Excellence in Health Service Delivery and quality of care – Excellence in Leadership and Governance – Excellence in Health Infrastructure and Resources 41 Health strategies/plans… • The prospective of HSDP (its focus) three: – the community perspective that try to answer the questions of how to enable the community to produce its own health; – Financial prospective that deals with the question of how to mobilize and utilize more resources effectively and efficiently; and – Capacity building prospective to deal with, what capacities must the health sector to excel in the processes. 42 Health strategies/plans… • A strategic map is drawn to illustrate the cause and effect relationship of strategic objectives in the health sector. • The map provides an insight how the Health sector is planning to establish an added value to the community and how the outcome and the customer value proposition intended results are achieved. 43 Health sector strategy map 44 Health strategies/plans… • Strategic objectives are used to break strategic themes into more actionable activities that lead to strategic results. • Strategic initiatives are long term or short term projects or programs that should be implemented to ensure success of the strategy. • Selected in terms of their potential to bring significant impact in the sector’s strategy. 45 Health strategies/plans… Strategic Directions for HSDP IV: 1. Health Extension Program 2. Quality of Healthcare 3. Scaling up of Civil service Reform 4. Human Resources Development 5. Health Infrastructure (Construction and ICT) 6. Special Support to Emerging Regions 7. Climate Changes and Health 8. Gender Mainstreaming 46 Summarized priorities and targets of HSDP IV (source: HSDP IV) Priority Maternal & New born Health Impact Outcome MMR 267/100,000 (from CPR= 66%( from 32%) 590/100,000) Delivery by SBAs = 62% (18.4%) Child Health U5MR 68/1000 (101/1000) IMR 31/1000 (77/1000) Fully Immunized= 90%(77%) Pneumonia Rx=81% HIV/AIDS TB HIV incidence 0.14 (0.28) ART =484,966, PMTCT= 77% Malaria Lab confirmed Malaria incidence <5 per 1000 Nutrition Stunting prevalence 30%(from 47%), Wasting Mortality due to all forms TB case detection 75% of TB= 20/100,000 prevalence 3%(from 11%) Pregnant mothers who slept under treated LLN =86% U5 TLLN =86% IRS=77% of Targeted HHs Bloodlines HEP HDA Supply chain management Regulatory system Harmonization and Alignment HCF HRD HIS Continuous QIP Referral system Health Extension Program Health Extension Program: • Provides integrated preventive, promotive and basic curative services at community level. • Furthermore, at all levels, programs are integrated at the point of service delivery. 48 Health Extension Program… 1. Family health services o Maternal and New born care – Antenatal care – Delivery services – Post natal care o Child health services – – – – Integrated management of Childhood Illnesses (IMCI) Growth Monitoring and Promotion Immunization Promotion of essential nutritional action (ENA) o Family planning services o Adolescent Reproductive Health Services 49 Health Extension Program… 2. Communicable Disease Prevention and Control Services: Primarily focus on – – – – Malaria Tuberculosis HIV/AIDS/STI Epidemic diseases 3. Hygiene and Environmental Health Services: Control of insects, rodents and other stinging animals Ensuring water safety and availability Proper housing Food sanitation Waste disposal including proper latrine usage 50 Health Extension Program… 4. Basic Curative care and Treatment of major chronic conditions First aid for common Injuries and emergency condition Treatment of major Chronic Conditions and Mental disorders Treatment of Common Infections and complications 5. Health Education and Communication Services Information, education and communication activities 51 Health strategies/plans… 3. Costing and Financing of HSDP-IV • Evidences so far strongly point out that the primary obstacles against fast and sustainable targeted health gains through implementation of the proven high impact interventions are lack of resources and weak implementation capacity. 52 Health strategies/plans… • low level utilization of existing proven effective interventions – require working more on community education and mobilization aimed at substantially increasing the demand and the timely utilization of the available health care services at each level of the health care system. 53 Health strategies/plans… Major Health Related Legislations in Ethiopia • The history of health and health related legislation in Ethiopia dates back as far as the early 19th century. • The first health decrees were vaccination against smallpox – smallpox epidemic in 1886. – During Emperors Yohannes and Menelik II, • Modern medical legislation could be traced back to the coronation of Emperor Haileselassie I in 1930. 54 Health strategies/plans… • On July 18, 1930 a law was passed to regulate the practice of doctors, dentists, pharmacists, midwives and veterinarians. • The law specified that no one could practice these professions without a relevant diploma. • In 1942 (proc. 27), traditional medicine was given a formal recognition. • 55 Health strategies/plans… • Between 1941and present time, some 27 Public Health enactments were made available: – Public Health Proclamation (NG 91, 1947, 66-68) – Medical Practitioners Registration Proclamation (NG 100, 1948, 1-3) – Establishment of Ethiopian Pharmaceutical Manufacturing Factory NG 167/1994 56 Health strategies/plans… • Council of Minister of regulation established regulation no (NG 174/1994) to provide for licensing and supervision of Health service Institution. • Establishment of the Pharmaceutical and Medical supplies import and wholesome sale enterprise (NG 176/1994) • Nutrition Research Institute Established under council of ministry of regulation( NG 4/1996) 57 Health strategies/plans… • Establishment of Health Education Center NG 40/1998 • Establishment of Ethiopian Health Professional Council (NG 76/2002) • Establishment of FMHACA ( Regulation No 661/2009) • Currently, there are more health regulation initiatives on the pipeline under the newly reorganized FMHACA. 58 Healthcare Regulation System • Regulation usually intends to ensure that providers are able to deliver quality care by ensuring the quality of the physical facility, medical personnel, equipment, and supplies. • Customers started to bother not only about getting treatment but also about their health outcomes. 59 Healthcare Regulation System… • Quality is ensured basically by regulating health practitioners and health service providers through the following three approaches: 1. Licensing 2. Certification 3. Accreditation 60 Healthcare Regulation System… 1. Licensing – It is a mechanism by which an executive organ or authority gives permission to an individual practitioner to engage in an occupation or to a healthcare institutions to operate and deliver health services. – Helps governments to ensure public health and safety by controlling the entry of healthcare practitioners and service provider facilities into the country’s healthcare market and by establishing standards of conduct for maintaining that status. 61 Healthcare Regulation System… A. Facility Licensing is the process of judging a health care facility or practice against a set of standards that specify the minimum structure that must be fulfilled in order for the facility to operate. Licensing standards specify the equipment, staff, and physical facilities that are essential for delivering medical care. 62 Healthcare Regulation System… • If the facility meets these standards it is granted a license to open and provide healthcare to clients. • Licensing of health care facilities is mandatory. • The goal of licensing is not to define desirable quality but to define the minimum acceptable level of capability to deliver service 63 Healthcare Regulation System… B. Health practitioners licensing • Health practitioners’ licensing is the process by which a regulatory body based on preset standard requirements issues permission to an individual to practice his or her respective profession. • Licensing is mostly mandatory. • Usually granted on the basis of examination or proof of education, or both, rather than on measurement of actual performance. 64 Healthcare Regulation System… • The regulatory body by issuing a license certifies that those licensed have attained the minimal degree of competency necessary to ensure reasonable protection of public health, safety, and welfare. • Regulatory body can be a Government or Professional Associations, independent Council or Board. 65 Healthcare Regulation System… • The regulatory body is accountable to: – Set standardized requirements for licensing health practitioners – Examine applicants’ credentials to determine whether their education, experience, and moral fitness meet the preset legal and administrative requirement – Administration of examinations to test the academic and practical qualifications of medical graduates against preset standards – Granting of licenses on the basis of reciprocity or endorsement – Investigation of charges of violation of standards established by law and appropriate regulatory measures: suspension or revocation for violators. 66 Healthcare Regulation System… 2. Certification – is a process by which a recognized authority evaluates and recognizes an individual provider or an organization as having met pre-determined requirements, usually to demonstrate competence in a specialty area. – Unlike licensing certification programs are usually voluntary, and give certified persons special recognition or authorization to use a particular title or official designation. 67 Healthcare Regulation System… – Certification makes practitioner feel he or she is the best qualified to do particular work, which should result in a professional attitude and motivation to improve competence. – Certification also enables the public to identify practitioners who have met a standard of training and experience set above the level required for licensure. 68 Healthcare Regulation System… 3. Accreditation is the formal process by which a recognized accrediting body assesses and recognizes that a healthcare organization meets pre-established performance standards. Accreditation standards are usually regarded as optimal yet achievable and are designed to encourage continuous improvement efforts within accredited organizations. 69 Healthcare Regulation System… The standards used to assess performance for accreditation are commonly developed by expert committees working with the accrediting body and revised periodically to reflect advances in technology or policy changes. By focusing on optimal rather than minimum standards of care, accreditation instills a strong performance improvement orientation, stimulating healthcare organizations to pursue increasingly higher levels of quality. Unlike licensing accreditation is voluntary. 70 HIS Policies and Procedures • Legal, regulatory and planning context of health information is a key resource for effective HIS. • It enables the establishment of mechanisms to ensure data availability, exchange and quality. • Legal and policy guidance is needed to elaborate specifications for health information access and to protect confidentiality, etc. 71 HIS Policies and Procedures… • Ethiopia has established a functional central HIS unit under FMoH • However, it lacks to develop and implement clear policies and procedures related to capturing, storing processing, and transmitting and communicating/disseminating health information in the country. • This doesn’t include the HMIS four technical areas on selected national health indicators and standardized data, recording and reporting tools with the procedures that apply to the HMIS only. 72 HIS Policies and Procedures… Health Information Related Initiatives overall objectives of the Health Management Information System are: – Develop and implement a comprehensive and standardized national HMIS and ensure the use of information for evidence based planning and management of health services. – To review and strengthen the existing HMIS at federal, regional, woreda, health facility and community levels and ensure use of health information for decision making at all levels. – To achieve 80% completeness and timely submission of routine health and administrative reports. – Achieve 100% of evidence based planning at woreda health office and hospital level. 73 HIS Policies and Procedures… The strategy for implementation of HMIS objectives are: – Institutionalize HMIS at all levels. – Build capacity of health workers to analyze, interpret and use health information for DM. – Introduce appropriate HMIS technology at all levels of the health system in collaboration with the concerned bodies such as the National Information, and communication technology (ICT) Authority. 74 HIS Policies and Procedures… – Define the minimum standard of inputs required for HMIS at different levels of the health system. – Initiate and sustain regular program review and feedback system. – The breakdown of the plan is detailed according to what activities are carried out by the various levels in the healthcare system. 75 HIS Policies and Procedures… A. Woreda Health Offices level: – Establishment of HMIS posts and assignment of appropriate personnel in the organizational structure as per the national standard. – Determination of the qualification requirements, job descriptions, career path, and incentive package standards for personnel working on HMIS. 76 HIS Policies and Procedures… – Ensure the proper reporting and feedback mechanism is laid out beginning from HEWs to the HMIS personnel at woreda level. – Provide the necessary health and administrative reports to the RHBs as per the guideline. – Allocate funds for HMIS and provide the necessary facilities for the HMIS units/personnel. – Implement and monitor HMIS in collaboration with the RHBs. – Collaborate on the expansion of the geographic information system and woreda connectivity. 77 HIS Policies and Procedures… B. Key Activities at RHB level: – Adapt and implement qualification requirements, job descriptions, career path, and incentive packages for personnel working on HMIS at different levels of the health system. – Adapt and implement National HMIS Strategy, manuals and standards developed at national level. – Conduct regular on-the-job training to HMIS focal personnel, program managers and health workers. 78 HIS Policies and Procedures… – Equip HMIS units at all levels. – Implement HMIS in collaboration with the FMOH. – Collaborate on the establishment of electronic network from federal to woreda level as part of implementation of HMIS. – Initiate and sustain the development of Health and Health Related Indicators in the regions. – Advocate the allocation of adequate funds for implementation of National HMIS in woredas. 79 HIS Policies and Procedures… C. Key Activities at the FMoH level : –Assign a multidisciplinary team at Planning and Programming Department –Provide the necessary facility so that it will be able to spearhead the development and implementation of HMIS at national level. –Develop and popularize the National HMIS Strategy and user-friendly manuals. 80 HIS Policies and Procedures… • Develop and popularize qualification requirements, job descriptions, and career path and incentive packages for personnel working on HMIS at different levels of the health system. • Standardize HMIS indicators; harmonize the reporting system and collect gender, age and facility type disaggregated data. 81 HIS Policies and Procedures… • Develop, adapt and implement HMIS userfriendly guidelines and revise International Classification of Disease (ICD) coding system. • Initiate pre-service training on HMIS in health professional training institutions. • Implement HMIS on pilot basis before nationwide replication. • Mobilize funds for implementation of National HMIS. 82 HIS Policies and Procedures… • Conduct system analysis for the application of ICT to HMIS, pre test and • implement the application and expand geographic information system. • Monitor the implementation of program review and research recommendations through HMIS. • Publish Health and Health Related Indictors bulletin annually. 83 Assessment-2 1. What are the strategies to be followed to achieve HMIS objectives? ____________________________________________________ ____________________________________________________ 2. Who is/are responsible for granting college accreditations in Ethiopia? ____________________________________________________ 3. Describe the essential health service package of Ethiopia ____________________________________________________ ____________________________________________________ 4. What are the major components of HSDP IV ____________________________________________________ ____________________________________________________ 84 Assessment-2 5. Describe at list two HMIS related activities performed at different level in the health care system. 6. Explain the differences and similarities of and i. Licensing, ii. Accreditation iii. Certification 7. Identify the main core elements of Ethiopian Health policy 85 3. Health Service Planning Learning objectives At the end of this topic you should be able to Define planning Identify types and features of planning Distinguish the different approaches of health service planning Assist in Developing, implementing and monitoring health service planning 86 Basics of Health Service Planning Planning is defined as a systematic process of identifying and specifying desirable future goals and outlining appropriate courses of action and determining the resources required achieving them (WHO, district health service planning) Basics of Health Service Planning… Others may define it in a beat different way as follows. Deciding in advance what to do, how to do it, when to do it and who to do it. It bridges the gap from where we are now to where we want to go. Combination of compiling and analyzing, information dreaming up ideas, using logic and imagination and judgment in order to come to a decision about what should be done Basics of Health Service Planning… A systematic process of identifying and specifying desirable future goals and outlining appropriate courses of action and determining the resources required to achieve them. Basics of Health Service Planning… Why planning? Planning health service programs in the health sector is essential to meet the following purposes. Fundamental: reach the objectives of the organization Protective: to minimize risk by reducing uncertainties surrounding the organization and outline management action. Affirmative (confirmatory / positive): to Increase the degree of organizational success Basics of Health Service Planning… Economy in operation: helps us to select the best alternatives that help us to achieve the best result at a minimum cost possible. It helps for effective utilization of resources. It improves the efficiency of the operation, better utilization of resources. To provide a basis for monitoring and controlling work: Fundamental purpose is to help organization reach its objectives). Basics of Health Service Planning… Health services planning may be defined as the process of defining community health problems, identifying needs and resources, establishing priority health goals, and setting out the administrative actions needed to achieve those goals. Basics of Health Service Planning… The primary aim of health planning is to improve the health status of a given population while safeguarding equity and fairness of access as well as responsiveness of the health system to the needs of the population. The health plan should achieve this goal through the provision of efficient and effective health services, taking into account available resources and the available means and methods of health care delivery. Basics of Health Service Planning… Depending on the time a plan is prepared for, it can be: Annual /Operational Plan : contain details for carrying out or implementing, those plans in day-to-day activities. derived from and in harmony with strategic planning and establish sub-objectives along with operational programmes, policies and procedures in major units of the organization such as departments Midterm plan: when the health plan go beyond one year and covers two to three years. Basics of Health Service Planning… Strategic plan: designed to meet an organization’s broad goals and focus on environmental assessment and addresses objective and strategy It also known as long term plan. The HSDP ( each phase comprises of 5 years duration) is a good example. Basics of Health Service Planning… Principles of planning One Plan, One Budget, One report, is the idea that all the major activities happening at various levels of the health system are included in one joint plan Evidence based and Flexibility. Basics of Health Service Planning… “One plan” means that all stakeholders (government (both federal and regional), donor, NGOs and the community) agree to be part of a broader sectoral plan. The health sector will have one country-wide shared and agreed strategic plan (HSDP) developed through extensive consultation. All other regional, zonal, woreda and facility plans will be local sub-sets of this strategic plan and should be consistent with the latter. Basics of Health Service Planning… The HSDP at all levels will have annual plans which are developed in similar consultation process. One Budget: ideally means all funding for health activities are pooled and channeled through government channels. However, there is also a less radical definition of “one budget” – all funds for health activities reflected in one plan and one documented budget, but actually disbursed through separate channels. Basics of Health Service Planning… One Report: A set of indicators has been identified to monitor progress in achieving HSDP. Reports should be based on these indicators and the agreed one plan without duplicating the channels of reporting Basics of Health Service Planning… Evidence Based: Planning in the health sector should be conducted with the help of concrete, complete and reliable evidence. Based on the evidences root causes of health problems of the society should be identified and tackled using proven high impact and low cost interventions. Furthermore, a logical and systematic approach should be used to define Strategic Objectives and performance measures. Basics of Health Service Planning… Flexibility: Plans should have some degree of flexibility in a way that important revision is possible therefore; plan should be revised as needed. The new planning process recognized this fact and considered flexibility as principle of planning in the health sector. Basics of Health Service Planning… Planning steps There are basic steps in the planning process that make a continuous cycle of planning and 1. Situation analysis 2. Problem analysis and prioritization 3. Setting objectives and targets 4. Developing interventions 5. Determining resource requirements Basics of Health Service Planning… 6. 7. 8. Preparing plan of action Implementation Monitoring and evaluation Basics of Health Service Planning… 1.Situation analysis involves assessment of the current situation from various perspectives to establish the actual health situation in terms of needs and priorities. Includes critical analysis of the previous plan ,reviewing the existing policy guidelines in order to familiarize yourself with the existing directives and regulations to be followed; and identifying problems with giving consideration to health and health-related problems based on available data from: HMIS, community surveys, census and your own experience. Basics of Health Service Planning… The identified problems can be categorized as primary health problems (illness such as HIV/AIDS, Tuberculosis, and Malaria) or secondary health problems (like inadequate health resources, poor service coverage). Basics of Health Service Planning… 2. Problem analysis and prioritization is the art of critical examination of problems against existing health related conditions of your region or zone or woreda. Once the major problems have been identified, their causes should be analyzed by asking and finding out why they exist. The analysis can be done by using tools such as route cause analysis. Basics of Health Service Planning… After you identified the prevailing problems and their route causes, you need to rank them based on their order of importance and this process is known as problem prioritization. Prioritization is making decisions on how limited resources could be best allocated to priority health problems or needs. Basics of Health Service Planning… 3. Setting objectives and targets An objective is the intended result of a successful activity or program within given inputs and process. Objectives will be formulated to address the identified priority problems and their immediate causes Basics of Health Service Planning… Objectives should be specific, measurable (or at least observable), attainable (given resources, environment and management capacity), realistic and time-bound (SMART). After you set objectives, you need to specify the number and quality of activities that has to be carried out to realize the objectives. Such determining amount of activities to be performed is known as setting targets. Basics of Health Service Planning… 4. Developing interventions answer questions like what do we need to do to get there and the options( alternate course of actions) with details of tasks or interventions to be carried out, by whom, during what period, at what costs and using what resources in order to achieve set objectives and targets. Basics of Health Service Planning… 5. Determining resource requirements allows to translate all activities of the intervention(s) to resources such as money, human resource, time and information. Example: resource requirement to distribute 5000 ITN to a certain rural kebele may need the following resources to be available. Human resource: one driver, 5 daily laborer, 1 malaria expert, 1 cashier Basics of Health Service Planning… Money: 20,000 birr for the net, 10,000 for salary/labor cost and 1,000 fuels Information; baseline information and information on the progress and effect of distributing the ITN in that particular kebele. Basics of Health Service Planning… 6. Preparing plan of action A plan of action is usually prepared in a tabular format and will normally contain the following items: the problem, objective(s)/interventions, activities, inputs, responsible body, implementer, activity monitoring indicator, planned output, activity cost and implementation time frame. Basics of Health Service Planning… 7. Implementation Once the planning and budgeting has been completed and approved by the appropriate authority, the success of the plans will depend on how well they have been implemented. There are three aspects that should be kept in mind while implementing the plan of action. Basics of Health Service Planning… Effectiveness: Effectiveness refers to what extent the particular activity outputs have been achieved as compared to the targets set. In order to achieve the objectives set in the plan of action, all activities should be fully implemented, reaching the set targets and covering all the activity components. Efficiency: It relates the output to the resource inputs (human resources, financial resources, time, and other materials) and refers to the measure of output per unit resource input. Basics of Health Service Planning… Timeliness: While preparing the plan of action, activities are planned to be implemented within a given period of time. Proper implementation of activities requires prior preparation in identification of resources needed, allocation of tasks and setting deadlines. These deadlines and allocated tasks should be made known to all members of the team involved in the activity. This will ensure timely completion of activities. Basics of Health Service Planning… 8. Monitoring and evaluation The key question to be addressed at this stage of the planning cycle is “how will we know when we get there and what have we achieved?” Basics of Health Service Planning… Planning Approaches The common methodologies of planning are: a. b. Top-down and bottom-up Balanced Score Card framework Basics of Health Service Planning… Top-Down and Bottom-Up Approach Health sector planning in Ethiopia follows TopDown and Bottom- Up approach. A top-down approach means an indicative plan produced at higher level and cascaded to lower levels At federal level national indicative plan with disaggregated targets by region is developed in consultation with RHBs and then will be sent to the lower levels. Basics of Health Service Planning… The indicative plan is important to give direction and align the plans at all levels with the priorities. Based on the indicative plan lower level will prepare comprehensive plan that will be finalized jointly with higher level and aggregated to the upper level. Basics of Health Service Planning… Bottom-up approach : issues at grass root level will be reflected at the regional and national levels, the regional and national level plans will therefore rely on the actual conditions existing on grass root levels. Furthermore the strategic and annual plans at all levels should be: 1. Linked with resource mapping process 2. Approved by relevant government authority 3. Linked to each other (strategic- Annual) 4. Comprehensive Basics of Health Service Planning… Balanced Score Card (BSC) is a strategic planning and management approach that help everyone in an organization understand and work towards a shared vision and strategy. The logic of BSC strategic planning starts at high strategic altitude, mission, vision and core values which are translated in to desired strategic results. Basics of Health Service Planning… Once the strategic thinking and necessary actions are determined, annual program plans, projects and service level agreements can be developed and translated into budget requests. Basics of Health Service Planning… Features of planning Futuristic anticipate the future what is required and how it will be accomplished Decision making determine what is to be done, when, where, how, and for what purpose. choosing among the alternatives. Resource allocation. Continuous and dynamic Why? because planned activities are affected by internal and external factors. Basics of Health Service Planning… Planning involves selection of suitable course of action. Planning is undertaken at all levels of the organization because all levels of management are concerned with the determination of future course of action. Planning is flexible as commitment is based on future conditions, which are always dynamic (changing). Planning is a continuous managerial function involving complex processes of perception, analysis, conceptual thought, communication, decision, and action. Activity -3 1. What is health service planning? 2. Explain the different features of planning 3. Discuss the different types of planning 4. Describe the steps of planning 5. Explain purposes of health service planning 6. Discuss principles of planning 7. Describe the common health service planning approaches128 5. Ethics and Laws in Medical Record Handling Learning objectives On completion of this topic, you should be able to: – Define ethics, code of practice and professional obligation of Health Information technician(HIT) – Identify health related laws applicable to HIT – Identify ethical principles to be followed while handling medical records – Recognize the ethical and legislative environment in relation to HIT in Ethiopia – Explain the applications of ethics and law to HIT 129 Ethics and Health Related Laws • Ethics is a branch of philosophy dealing with moral principles that may be connected to beliefs about what may be considered wrong or right. • It is the science of moral value. • is derived from the Greek word “ethos” meaning “the set of moral principles” or • “a system of moral principles” or “rules of behavior”. • An ethical behavior is one that is considered to be morally correct or acceptable. 130 Ethics and Health Related Laws… • There are different kinds of ethics. Ethics can be categorized in accordance with the subject matters it deals with like: – medical ethics, bioethics, information ethics, economic ethics, journalistic ethics, and communication ethics, legal ethics etc. The focus of this topic will be information ethics. 131 Ethics and Health Related Laws… Professional ethics • is the application of the concept of ethics to a person who belongs to a learned profession or whose occupation requires a level of training and skill. • Professionals are capable of making judgments, applying their skills and reaching informed decisions in situations that the general public cannot, because they have not received the relevant training. 132 Ethics and Health Related Laws… • Professional people and those working in acknowledged professions exercise specialist knowledge and skill. • How the use of this knowledge should be governed when providing a service to the public can be considered a moral issue and is called professional ethics. • Health information technicians, who are practicing their profession, must act and work within the basic principles and guidelines for morally acceptable behaviors in relation to their profession. 133 Ethics and Health Related Laws… Code of Ethics • A Code of Ethics, in its formal sense, is an attempt by an organization to codify the values of the group i.e. a statement of overarching principle telling members what is right and what is wrong as a guide to all decision making within the organization. 134 Ethics and Health Related Laws… • Codes of ethics set out general principles, often social or moral, that guide rather than dictate behavior. • Codes of professional ethics serve several purposes such as: – It provides ethical guidance for the professionals themselves – It furnishes a set of principles against which the conduct of the professionals may be measured, and 135 Ethics and Health Related Laws… • It provides the public with a clear statement of the ethical considerations that should shape the behavior of the professionals themselves. • Moreover, since the field of health information is in a state of constant change, it should be flexible so as to accommodate ongoing changes without sacrificing the applicability of its basic principles. • It is therefore inappropriate for a Code of Ethics for HITs to deal with the specifics of every possible situation that might arise. 136 Ethics and Health Related Laws… • Instead, such a Code should focus on the ethical position of HITs as a professional, and on the relationships between HITs and the various parties with whom they interact in a professional capacity. • These various parties include (but are not limited to) patients, health care professionals, administrative personnel, health care institutions and governmental agencies. 137 Ethics and Health Related Laws… Major ethical principles and standards of ethics in HIM • Ethical principles are an important tool to protect the privacy and confidentiality in HIM • These ethical principles provide a framework for analyzing and resolving ethical problems. • Involvement in the protection of individual health record requires observance of ethical principles which must not be violated. 138 Fundamental Ethical Principles 1. Principle of Autonomy – All persons have a fundamental right to selfdetermination. – Autonomy implies an individual is master of himself/herself and he/she can act, make free choices and take decisions without the involvement of another person. – However there are pre-conditions for the application of autonomy principle, which are: 139 Fundamental Ethical Principles… – Competency of a person i.e. is the capacity to be a moral agent, for example a person who is 18 years and above in Ethiopia is competent and Liberty or freedom. • The principle of autonomy is based on the value of giving due regard to clients view and respecting their choices. • For example, autonomy in health information management would requires that HIT’s must make sure that the client, not a spouse or third party, is making the decision regarding access or disclosure to a third party about its private health information. 140 Fundamental Ethical Principles… 2. Principle of Equality and Justice • All persons are equal as persons and have a right to be treated accordingly. • Justice means “fairness” which implies giving each person/ client what he or she deserves. • Justice requires you that “equals be treated equally and un-equals unequally”. 141 Fundamental Ethical Principles… • As a matter of principle all clients are equal as they all come for health service and therefore need to be treated equally. • However, in some circumstance this principle may not work. – For example when there is an emergency a physician may need immediate access of the clients’ health record, which must be pulled out ahead of other patients’ who are already waiting in line. – In this circumstance, client may be treated differently than those who may be waiting to access their own health information. 142 Fundamental Ethical Principles… 3. Beneficence and Non-Maleficence • The principles of beneficence and non- maleficence are best considered together, as they are complementary principles. • In simple terms, beneficence means doing good and non-maleficence means avoiding evil or harm. • The first one states that “All persons have a duty to advance the good of others where the nature of this good is in keeping with the fundamental and ethically defensible values of the affected party”. 143 Fundamental Ethical Principles… • The second principle is “All persons have a duty to prevent harm to other persons in so far as it lies within their power to do so without undue harm to them”. • The principles of beneficence and nonmaleficence translate into the duties to maximize benefits while minimizing harms. 144 Fundamental Ethical Principles… • Beneficence would require HIT’s to ensure proper information disclosure. – the information is released to individual who need it for something that will benefit the client; including continuation of care, or for health insurance payment purposes. • On the other hand the principle of non- maleficence would require that a patient’s information is not released to someone who does not have the legitimate authorization to access it, and who might harm the client in some way if access were permitted. 145 Fundamental Ethical Principles… • This may happen for example, when an employer seeks to use health information for discriminatory purposes in employment. 146 Professional Obligations • Ethical and professional obligations in HIT can be categorized into six categories. • Each category demarcates the different domains of the ethical relationships that exist between HITs and specific stakeholders. These categories are: 1. Obligations to client 2. Obligations to colleagues in the health care team 3. Obligations to the employer 4. Obligations to the public 5. Obligations to self 6. Obligations to professional association 147 Professional Obligations… 1. Professional obligation to client and the health care team • In the course of performing ones professional duty, the following major obligations towards clients and colleagues must be observed: – With regard to the patient and the health care team, HIT personnel is obliged to provide the necessary services to those who seek access to client information in accordance with the applicable rule. – Individuals who may request access to client information include health care professionals or even the client himself or herself. – Here you must ensure the honor of the profession and the health and well-being of client before all personal and financial interest. 148 Professional Obligations… – HIT personnel are expected to protect both the medical and social information of the client. – Clinical information, like diagnoses, procedures, or genetic data must be protected as well as behavioral information like the use of drug or alcohols, and sexual habits. – Particularly it is increasingly important to protect social information like drug abuse to avoid discrimination. 149 Professional Obligations… • HIT personnel are expected to protect confidential information of the client. • This involves ensuring the information collected and documented in the patient information system is protected by all members of the health care team and by any other person with legal access to the information. • HIT personnel should preserve and secure the health information in their control. • This includes obligation to maintain and protect the place where you stored the record (hard copy, electronic or imaged) and to secure the information in both manual and computerized information systems. 150 Professional Obligations… • HIT personnel have to promote the quality and advancement of health care in the institution they are serving. • As an important member of the health care team HIT personnel must provide their valuable expertise in the collection of health information that will help other healthcare providers to improve the quality of care they are delivering. 151 Professional Obligations… • HIT personnel need to observe their scope of responsibility to which they are assigned. • They must not make or pass clinical judgments. • Sometimes health care data may indicate a problem with a provider of care, the treatment of diagnosis or some other problems; in such cases the obligation of the HIT personnel is to provide data not to pass judgment. 152 Professional Obligations… • The obligation rest with the health care team that reviews the data. • The obligation of the HIT personnel is to report accurate result. 153 Professional Obligations… 2. Professional obligation to the employer • Demonstrate loyalty to employer. • This can be done by respecting and following the rules, policies and regulations of employment. – giving the employer adequate notice when the decision to change employment or resign is reached. – Observe all laws, regulations, and policies that govern health information management. – Keep up to date with regional and federal laws; employer policies and procedures affecting HIT. – Accept payment only in relation to work responsibilities. – HIT personnel must never accept money illegally by disclosing patient information and trading in patient secrecy. 154 Professional Obligations… 3. Professional obligation to the public • Advocate change when patterns or system problem are not in the best interest of the patient. • Protect clients, the health care team, the professional association and colleagues. • Refuse to participate in or hide unethical practices. 155 Professional Obligations… • Become accountable for noticing trends and potential problems with regard to providers of care, diagnosis and procedure. • Furthermore refuse to conceal illegal, incompetent, or unethical behaviors. • Report violation of practice standards to the proper authorities. • Avoid sharing information learned at work with family or friend, and avoid discussing such information in public places. 156 Professional Obligations… 4. Professional Obligation to self and professional association • Being honest about one’s education, credentials and work experience when applying for a job, • being careful to report only academic qualification attained, and submitting only document which are successfully earned. • In the HIT profession, personal competency and professional behavior is very important. 157 Professional Obligations… • HIT personnel must try to ensure that peers and colleagues are proud to have them in the health information team. • HIT personnel should set goal/ aim at advancing his/her career. – This can be done by not stopping his/her education when one has earned the professional qualification one is currently studying. – Rather try to continue to attend educational sessions to keep up to date with changing circumstances. 158 Professional Obligations… • Strengthen the health information professional association. • This obligation includes – becoming a member of a professional association, actively participating in different activities of the association, and encouraging others to seek a career in the health information field. • Promote and participate in health information research. When problems are discovered within a health information system, studies must be conducted to clarify their source and potential solutions. 159 Professional Obligations… • Despite the fact that HIT professional association not yet established in Ethiopia, professionals should contribute their faire share to the establishment of their professional association and obey the abovementioned professional obligations. 160 Law and Health Related Laws What is Law? • Law is defined as a set of rules or principles dealing with human activities and formally recognized as binding or enforceable by a controlling authority. • Laws are passed by government to keep society operating smoothly and to control behaviors that could threaten the public safety. • Enforcement of these laws is possible by penalties for violation which are decided by courts of law. Penalties vary with the severity of the violation. • Those persons who violate the law may be fined, imprisoned or both and professionals who violate laws may also lose their registration or license to practice their profession. 161 Law and Health Related Laws… Basis for a law • The Constitution of the Federal Democratic Republic of Ethiopia divides the power and responsibilities of the Federal government among: – The legislature - which is the law maker, – The executive - which is the law enforcer, and – The judiciary - which is the interpreter of the law. • The House of Peoples Representatives is the legislative branch which originates proclamation that becomes federal law. • The executive branch of the government (the Council of Ministers) through delegation from the House of Peoples Representatives can issue regulation. 162 Law and Health Related Laws… • In addition, administrative offices with delegation from the House of Peoples Representatives or the Ministers of Council can issue directives. • Directives are the lowest form of laws in the hierarchy of legislation. • In a country having a federal set up like Ethiopia, regions have also their own legislative, executive and judiciary organs exercising their powers and duties in the region. 163 Law and Health Related Laws… Health related laws • Health related laws are laws which set rules and principles relating to the health sector operation and includes a vast range of laws dealing with issues affecting the health and welfare of the people. • There are many categories of laws having direct or indirect application to the health sector in general and HIT in particular. • While this legislation varies from country to country, health related laws in general cover legislations related to: 164 Law and Health Related Laws… – – – – – – – – – – – – – Disease control and medical care, Health professional regulation Ethics and patients rights Health information and statistics Pharmaceuticals and medical devices Health institution and services Nutrition and food safety Occupational health and accident prevention Mental health Health insurance Smoking, alcoholism and drug abuse Environmental protection Criminal sanctions and human rights. 165 Law and Health Related Laws… • Among the above mentioned health related laws: – health information and statistics; – ethics and patients rights; – Health professional regulation and – human rights document are the major legislative documents which have direct or indirect application to the HIT profession and privacy and confidentiality of personal health information in particular. 166 Law and Health Related Laws… • Though HIT involves other professionals and support staffs, the HIT personnel are the primary custodian of the medical record and bear the primary responsibility in respect to this record. • This is because they are in charge of privacy and confidentiality protection in the course of handling, security and disclosure of the medical record. 167 Law and Health Related Laws… • In the Ethiopian context, some of the above mentioned legislative text can be generally found under the Constitution of the Federal Democratic Republic of Ethiopia and international human rights documents which Ethiopia endorsed such as the Universal Declaration of Human Rights and International Covenant on Civil and Political Rights. 168 Law and Health Related Laws… Difference between Ethics and Law • Both professional ethics and law share two fundamental goals: the regulation of behavior and the protection of society at large. Ethics and Law, therefore, share the goal of creating and maintaining societal good. • In respect to the HIT profession, the ethical and legal requirements aim at primarily the protection of privacy and confidentiality of personal health information of client/patient. 169 Law and Health Related Laws… • Though both ethical and legislative requirements strive to this end, ethics and law differ in a range of issues. • Professional ethics is a set of principles and in general require professionals to behave in a certain manner just because doing something is right or wrong. 170 Law and Health Related Laws… • An illegal act by a professional is always unethical but unethical act is not necessarily illegal. • This follows the issue of whether ethical standards are enforceable or not. • Though moral values are a beginning to the development of legal rules for social order, an ethics statement which is not adopted into law is generally unenforceable. 171 Law and Health Related Laws… • However, courts of law may see the ethics statements or principles of professional associations or regulatory bodies when they interpret laws affecting that profession. • Therefore, ethical standards influence legal standards by creating professional ethics standards 172 Law and Health Related Laws… • In contrast, law sets a general standard of conduct which must be adhered to or civil or criminal consequences may follow a breach of the standard. • These laws are written, approved and then enforced by the government body which approved of them. • In other words laws go through a process to get approved, then are written into laws, and then are enforced. 173 Law and Health Related Laws… • Enforcement of these laws is through penalties decided by courts of law. • This may include fines, civil or criminal penalties, depending on the gravity of the violation. 174 Law and Health Related Laws… Legal Framework and enforcement in HIM • Individual health record is known to be an important legal document. • This record has to do with the protection of clients’ legal right of privacy and confidentiality of the information and • it may be used in medical malpractice suit and settlement of health insurance payment. • There are various relevant issues that must be known by HIM personnel in order to fully grasp the legal implications when managing patients’ health record. 175 Law and Health Related Laws… • HIT professionals need to meet various legislative requirements in respect to collection, security, right of access, use and disclosure of the individual health information and ownership and control of the health record. • Therefore, it is very important to become familiar with all the requirements and standards set collection, security and rights of access to personal health information. • In addition, know and apply requirements on how the information can be used, and under what circumstances it may be disclosed. • have an important implication in the protection of the right to privacy and confidentiality of personal health information. • In addition, it is important to understand what the HIM personnel’s role and functions is in the life cycle of specific individual health information. 176 Law and Health Related Laws… • Legal responsibility of professional conduct may be civil liability or criminal liability. • Under civil liability of professional misconduct the person may be required to pay compensation to the person who suffers any damage by the act or omission which is done by the professional. • In the case of HIT professionals, anyone who discloses the personal health information of the client/patient in violation of any applicable law may be required by courts of law to pay compensation to a person whose privacy is unjustly disclosed. 177 Law and Health Related Laws… • In addition, within the legal procedure anyone who discloses personal health information may be held accountable for criminal sanction. • Where the HIT professional violates the privacy and confidentiality of personal health information in violation of legal requirements he/she may be required to suffer court process of criminal liability. • Depending on the severity of the breach, the professionals may be required to be fined or imprisonment. 178 Law and Health Related Laws… Medical Record as a Legal Document • Good medical records are essential not only for the present and future care of the patient but also as a legal document to protect the patient and the health institution. • For both purposes, they must be complete, accurate, and available when needed. • They must be used and stored according to all governing laws and also to the policies of the health facility. 179 Law and Health Related Laws… • Legally, medical records are used to support the patient’s claim in case of injury, for the protection of the attending doctor against claims of malpractice, and for the protection of the health institution against criticism and claims for injuries and damages. • Medical records are considered the property of the health institution and are compiled and kept primarily for the benefit of the patient. 180 Law and Health Related Laws… • The personal data contained in the medical record is considered confidential and the property of the patient. • That is, the information contained in a medical record belongs to the patient and is a confidential communication between the doctor or other health professional and the patient. 181 Law and Health Related Laws… • Although the physical medical record is considered to be the property of the health institution and the information in the medical record is the property of the patient, information cannot be released without the consent of the patient. • Exceptions to this rule include the use of the information: – By doctors and other health professionals for the continuing care of the patient. – For medical research where the patient is NOT identified, and – For the collection of health care statistics when the individual patient is NOT identified. 182 Law and Health Related Laws… • Situations in which Medical Records are used as Legal document • Medical records are generally used in court for the following: 1. 2. 3. 4. 5. 6. Worker's Compensation Personal Injury Claims Malpractice Claims Will case Criminal case Insurance cases 183 Law and Health Related Laws… 1. Worker's Compensation • A person injured in the course of his or her duties and while acting in the scope of his or her employment is entitled to compensation for bodily injury and disability. • The medical record is used as evidence to show the date of injury, the type and severity of injury, and the patient’s expected recovery. 184 Law and Health Related Laws… 2. Personal Injury Claims • A person may claim to have been injured through the fault or neglect of another and sues to recover damages for injuries sustained. • The medical record would be used to show how the injury happened as recorded in the patient’s words on admission to the hospital. • The medical record would also be used to show the extent of the injuries, treatment given, duration of care and expected recovery or disability. • It is the most frequent situations by which Medical records are used as evidence. 185 Law and Health Related Laws… 3. Malpractice Claims • In this type of case the Plaintiff (person suing) claims damages from a doctor, a hospital, nurse or other health professional for negligence in rendering care or giving improper treatment. • The medical record would be used to show that there was no negligence and that treatments rendered were adequate and proper. 186 Law and Health Related Laws… 4. Will Case • A patient may have made a will during his or her health institution stay. • After the death of the patient, an attempt may be made to set aside the will by seeking to prove that the patient was not mentally incompetent. • The medical record would be used to show the mental state of the patient at the time of making the will. 187 Law and Health Related Laws… 5. Criminal Cases • Medical records have been used in many criminal cases and the most frequent use includes: • Assault cases: to prove the assault and extent of injuries. • Violent or unexplained death: to prove death resulted from natural causes, accident, misadventure or murder. • Sexual assault cases: to prove the condition of a patient on admission or attendance at a hospital and the history of the assault related by the patient. • Mental competency: hospital medical records may also be used as evidence in proving the mental condition of a patient. 188 Law and Health Related Laws… 6. Insurance Cases • Used by the patient for proof of injury and/or disability in personal accident cases or by the insurance company to disclaim responsibility. • In order to treat medical records as legal documents, the following points should be considered in your daily practice of handling them: – Use blue or black ink unless you are using a computer. – Do not use pencil or ink that can be erased. – Write so that it can be read clearly, sloppy writing causes errors. – Date all of your notes. 189 – – – – – – – – Write the time that you took your notes. Sign your full name and title. Do not use white or any other cover up for mistakes. Write only the facts. Never add personal comments or feelings. Do not use abbreviation unless they are accepted for use by your health institution. Do not allow anyone to touch or look at your medical records unless they are a healthcare worker assigned to take care of the patient. Keep all medical records in a safe and secure place. Medical records are confidential. Do not disclose or discuss any facts of the patient or their care with anyone other than the assigned healthcare staff or the patient themselves. 190 Application of Ethics and The law in HIT • The laws and ethics governing the provision and maintenance patients’ privacy protection and confidentiality have a broad application in the HIT profession. • The following is expected of HIT personnel: – To bring about honor in the course of professional service to the HIT profession; – To advance HIT knowledge and practice through continuing education, research and dissemination; – To state truthfully and accurately your credentials, professional education and experiences; – To facilitate interdisciplinary collaboration in situations supporting health information practice; – To respect the inherent dignity and worth of every person and refuse to participate in all unethical practices or procedures. 191 Application of Ethics and The law in HIT… • Furthermore, in the course of collection and use of patient’s personal information, ethical requirements demand the utmost security must be maintained during disclosure of personal health information in order to ensure privacy and confidentiality of personal health information. 192 Application of Ethics and The law in HIT… • To keep personal health record secure patients’ information must not be disclosed unless it is relevant or necessary for service provision for the patient/client, for public use, and where there is valid consent and other justifiable grounds in accordance with the relevant laws and regulation. 193 Application of Ethics and The law in HIT… • In addition to ethical standards, Legislation require the collection, use, security and disclosure of personal health information in a certain manner and all health professionals are expected to work in line with these legislative standards where applicable. • The principles applicable to the collection, use, security and disclosure of this information will be useful for standard service delivery to the patient/client and protection of confidentiality, research purpose and management of the health system, including: – planning, resource allocation, policy development, monitoring and evaluation and reporting. 194 Application of Ethics and The law in HIT… • However, in one way or another, all these rules regarding the collection, use, security and disclosure of this information have to do with the protection of the right to privacy and confidentiality of personal health information. • Though we do not currently have separate law governing HIT, the Constitution of the Federal Democratic Republic of Ethiopia (FDRE) and other international human rights documents to which Ethiopia is a member and party like the Universal Declaration of Human Rights (UDHR) of 1948 and the International Covenant of Civil and Political Right (ICCPR) of 1966 provides the right to privacy protection. 195 Application of Ethics and The law in HIT… • Since the right of privacy may be violated in relation to collection, safeguarding and security, disclosure, right of access and transfer of health record and other related subjects, the rules related to these items can be taken as an explanation on how you should protect patients/clients privacy in the course of your professional activities. 196 Application of Ethics and The law in HIT… • Therefore it’s very important to see the positive application of both ethics and the law as vital in particular for the protection of privacy and confidentiality of personal health information which is one of the basic rights of patients/clients in our case and recognized under international human rights documents which Ethiopia guarantees to observe and protect. 197 Activity-5 1. Discuss about four fundamental principles of ethics (Define each term) and give examples for each. i. Autonomy__________________________ ii. Beneficence_________________________ iii. Non-Malfeasance_____________________ iv. Justice______________________________ 2. How can justice as a principle be applied in health information Technician? 198 3. Mention at least two major differences between ethics and law. 4. The application of ethics and law in the HIT is only for the protection of privacy of personal health information? Yes / No, give reason for your answer. 5. What will happen if professionals ignore applicable ethical standards? 199 6. Mention the different kinds of ethical and legal measures against persons who violate applicable rules of a profession? 7. Discuss various administrative (disciplinary) measures an employer can take against HIT professionals who violate his/her ethical and legal duty. 8. Explain the importance to use Codes of ethics? 200 Case-1: • Ato Solomon is working in Harar General Hospital as head of the medical record unit. He has read medical record documents of patient and learnt that the patient is drug/substance addicted. While chatting somewhere else with friends, a friend has raised an issue about the personality of that patient. During expressing his opinion about the person, Ato Solomon disclosed to his friends about patient’s drug addiction. Which professional obligation(s) is violated by Ato Solomon? Case-2: • When you have learned that your best friend has disclosed the patient’s social information illegally to an unauthorized person. What should you do? What dictates you to decide so? Is it not unethical to expose your best friend’s sin to others? 201 6. Patient Privacy and confidentiality of Health Information Learning Objectives At the end of this section the learner should be able to: – Explain concepts of patient confidentiality of information. – Apply patient’s privacy and confidentiality of patient information. – Identify patient/client right to access of care. – State ethical standards related to patient privacy right and confidentiality. – Describe general Medico-Legal principles in relation to patient Medical records 202 Privacy and Confidentiality • As health information technician, one should have clear understanding of these interrelated concepts. • Privacy is the right of every person to be left alone and no one can interfere in the personal life of the individual. • No matter that health record is in the possession of the medical record keeper physically, the information is still the property of the client. • Therefore, it is the client who has a say in his individual health information. 203 Privacy and Confidentiality… • Confidentiality means the responsibility of a health record keeper to limit disclosure of individual health information unless authorized by the client or specifically under law. • Includes the responsibility of professionals to use, disclose or release such information only with the knowledge and consent of the client. • Security includes physical or electronic protection of the integrity, availability and confidentiality of personal health information. • In addition, this responsibility extends to make sure that the mediums used to enter, store and communicate this individual health record are safe and secured. 204 Privacy and Confidentiality… • Accordingly the basic responsibilities in HIT are to provide privacy and confidentiality. • Ensure patient’s privacy, maintain confidentiality of information, and ensure data security measures are used to prevent unauthorized access to the patient’s information. • In addition, HIT personnel are expected to ensure that release policies and procedures of health institutions are followed properly, and all violations of privacy or confidentiality of individual health information are reported to the appropriate authority. 205 Privacy and Confidentiality… Release of Individual Health Information • Unlike in the past when only few people wanted access to the information contained in a patient’s medical chart, there are many more stakeholders who want to access this information. • Some of these are: – Insurance companies who want to determine the extent of the damage caused to the person eligible for insurance payment, and – Someone in a law suit who wants to challenge the health status of his accuser. 206 Privacy and Confidentiality… • The healthcare facility should develop a policy for the release of patient information. • It is important to ensure that all staff, not only in the Medical Record Unit, but also in all other sections of the health care facility, are aware of the policy and that it is followed. • There are four methods of releasing information: 1. Direct access to the medical record; 2. Supply abstract 3. Verbal release 4. Photocopying 207 Privacy and Confidentiality… • Unauthorized person cannot take any or part of a medical record out of file, or read, copy, or otherwise tamper with them. • If a request is made for the release of information, the request should contain the following: – – – – Full name of patient, address and date of birth; Name of person/persons or institution requesting information; Purpose and need of the information; Extent and nature of information to be released, including dates; and – A recently dated authorization, signed by the patient or authorized representative – E.g. parent or guardian of a child 208 Privacy and Confidentiality… Patient Consent for Release of Records – No information concerning a patient should be released to another person without the written consent to release information from his or her medical record, the information contained in it can only be released to a court by subpoena or a court order. – If a patient is under the age of 18 years or otherwise subject to a guardianship order, any consent for access to information should be given in writing by the patient's parents or legal guardian. – If the patient lacks the capacity to provide genuine consent then the written consent must be obtained from the person's legal guardian. In the case of a patient who has died, the written consent to access – information from the patient's medical record should be provided by the next of kin shown on the medical records. 209 Ethical standards related to Patient Privacy Right • Among other things health information privacy is vital for the following major reasons: 1. information privacy is a fundamental human right (with Constitutional protection which is the supreme law in Ethiopia). • It is a right that is essential to the dignity and integrity of an individual. • It should also be noted that the information is the patient’s property; it does not belong to anybody else. 210 Ethical standards related to Patient Privacy Right 2. Second, if appropriate health information privacy is not guaranteed, the client caregiver relationship will suffer negative impacts. • This means clients will not tell the necessary information or will avoid seeking care. • Therefore, the necessity for protection of individual health information is very important. • This right to privacy is understood as an individual right protected under the Constitution, international human rights documents like the UDHR and ICCPR and other laws. 211 Ethical standards related to Patient Privacy Right • The UDHR provides that no one shall be subjected to arbitrary or unlawful interference with his privacy, family, home or correspondence, or to unlawful attack on his honor and reputation. • The right to privacy is found to be very important in examining the protection of individual health information. • One aspect of the right to privacy is defined as: The right to be free from unlawful intervention of one’s personality, the publicizing of one’s private affair with which the public has no legitimate concern; or the wrongful intrusion in to one’s private activities. 212 Ethical standards related to Patient Privacy Right • Everyone has the right to the protection of the law against such interferences. • Therefore, HIT personnel are duty bound to protect individual health information from any kind of unlawful interference. 213 General Medico legal principles • The HIT must be familiar with the legal requirements regarding medical records as per the national policy to be able to cope with medico-legal problems. • The term Medico-legal is defined as something of or pertaining to the intersection between medicine and law. • The HIT must also be able to identify legitimate and illegitimate requests for information. • Remember that being used for patient care a medical record is also a legal document and should be treated accordingly. 214 General Medico legal principles… • No information concerning a patient should be released to another person without the written consent of the patient or the patient's legal guardian. • If the patient lacks the capacity to provide genuine consent, then the written consent must be obtained from the person's legal guardian. • Medical records should be kept under adequate security and only removed from the hospital or health care center upon receipt of a subpoena, statutory authority, search warrant, or court order. 215 General Medico legal principles… • When an original medical record leaves the hospital for legal purposes, a photocopy of the medical record is made beforehand and kept in the hospital until the original is returned. • The copy is subsequently destroyed. • The health care facility is NOT legally bound, however, to release information if it affects the health care facility or the attending health care workers. 216 General Medico legal principles… • The information requested is identified and the attending health care worker asked to write a report. • In many health care facilities a pre-designed form may be used if a discharge summary is already in the medical record, it is checked and if it includes all the requested information, a copy is made. • This will save the doctor having to write a new report. If the original medical record is needed, the lawyer must produce a court order or subpoena to enable the release of the medical record. 217 Example of format for a summary of medical record information for medico-legal case: • • • • • • • • • • • • • • • • • • Date:______________ To: (name of lawyer or law firm requesting information)____________________________ Dear ___________________ The following is a summary of the medical record of (patient’s name) __________________ Age: _____ living at (address)______________________________________________ ________________________________________________________________________ who was admitted to this hospital on (date of admission)_____________________________ and who was discharged (or died) on (date of discharge or death) ___________________ History: _____________________________________________________________ Physical Examination: ______________________________________________ Laboratory Reports: ___________________________________________________ X-Ray Reports: _________________________________________________________ Operation/Procedure: __________________________Findings: ____________ _________________________Pathological Report: ____________________________ ______________________________________________________________________ Final Diagnosis: ____________________________________________________ Result On Discharge: ______________________________________________ Signed: ___________________________(Attending doctor) 218 Activity: 6 1. 2. 3. 4. 5. Write the definition of privacy and confidentiality of patient information with your own words. Discuss Ethical standards related to patient/client privacy right and confidentiality of patient/clients information. Sister Askale is a Nurse who works as head of Medical wards in a nearby Hospital. She wanted the Health Information Technician to tell the diagnosis of Ato Feyissa Hailu who is the cousin of her husband and treated a month before in the medical outpatient department of the hospital. How do you respond to her request? Who do you think is the owner of the medical record and the information within the medical record? It is always prohibited to disclose personal health information without the consent of your client. True or False? Explain the reasons for your answer. 219 7. Security and Access to Health Information Learning Objectives At the end of this topic, you should be able to: • Identify issues related to the use and disclosure of individual health information • Identify common information security measures • Identify the legislative requirements for the collection and security of individual health information • Define the right of access to individual health information 220 • Security Measures to Patient/Client Medical Record • Medical records may be maintained as paper-based or computer records. Regardless of the • systems, health facility and individual staffs must take reasonable steps to protect the • personal information contained in the medical records from loss, unauthorized access, • modification or disclosure. Staffs, particularly the medical record unit staffs need to protect • medical records against such unauthorized access where those medical records are stored or • transmitted. A breach of the security measures in place should result in disciplinary action • with a range of penalties including dismissals. 221 • • • • • • • • • • • • • • • • • Handling Confidential Information Confidential health information must be stored, transported, transmitted, handled, used, and disposed of in ways that protect the information from unauthorized access, alteration, destruction, disclosure, copying, theft, or physical damage. However, such ways of handling medical records shouldn’t be obstacle to use the medical record for provision of care when needed. You must have security measures in place to protect work areas and patientidentifiable information. Some of the security measures for paper-based or electronic medical records are: • System access management • Personnel clearance procedures • Password protection of computer applications • Secure disposal of confidential waste • Sanctions for misuse of systems and data • Signed confidentiality agreements • Data backup and disaster recovery procedures • Assigned responsibility for confidentiality and security of information • Confidentiality and security awareness training 222 • • • • • • • • • • • • • • • • • Some good practices to meet security requirements are: • Policies, Physical and administrative safeguards: The medical record unit, computers and portable devices that contain patient health information should be physically protected from unauthorized access by means of a security measure such as having alarm systems or locking with key. Written policies and administrative measures like designating security officers, training the work force, controlling information access and periodic security reassessment through staff training and monthly review of user activities can minimize unauthorized access to patient information in the health facility. • Prevent Unauthorized or Inappropriate Access: Issue unique user names and passwords to everyone who will use the EHR (if accessed this way) to prevent unauthorized or inappropriate access to patient information and system controls. • Use Encryption Technology: Whether an EHR is locally installed or accessed over the Internet, encryption technology can protect patient health information from being read by unauthorized parties when it is transmitted, or stored on any device, including mobile devices. Encrypting personal health information puts information in a coded form that can only be read by an authorized user who has a “key.” 223 • • • • • • • • • • • • Backup: To keep information available when and where it is needed, plan for backing up your EHR system. Policies and Procedures to Health Information Access and Disclosure Medical record policy will endeavor to protect the confidentiality and security of its patient health information against inappropriate access, inappropriate use, tampering, loss/destruction and inappropriate disclosure through the use of reasonable safeguards. The purpose of this policy is to set forth the general principles and procedures for maintaining the confidentiality and security of patient health information. The medical record service shall be properly equipped to enable its personnel to function in an effective manner and to maintain medical records so that they are readily accessible and secure from un-authorized use. The organization policy should address the following areas. 224 • • • • • • • • • • • • The medical record unit shall have written policies and procedures that are reviewed at least once every three years, revised more frequently as needed, and implemented. They shall include at least: 1. Procedures for record completion, including chart analysis. 2. Conditions, procedures, and fees for releasing medical information. 3. Procedures for the protection of medical record information against the loss, alteration, destruction, or unauthorized use. • All entries in the patient's medical record shall be written legibly in ink, dated, and signed by the recording person. If computer generated orders with a physician's electronic signature are used (in case of EMR), the Health care facility shall develop a procedure to assure the confidentiality of each electronic signature and to prohibit the improper or unauthorized use of any computer generated signature. 225 • • • • • • • • • • • • • • • • Access and disclosure are usually associated with the concept of ownership and control of health information or the health record. Access of health information means using the personal health data internally within a health institution like a hospital or health center, however, disclosure relates with the manner how health information should be disseminated externally. In principle, medical records, x-rays, laboratory reports or other physical documents relating to the delivery of health care service are owned by the specific health institution. However, this doesn’t mean that the client have no right over the health record. Rather, the information within the record is the property of the client. It’s out of this concept that the client is granted the right to take a copy or view or otherwise access his/her health information or amends the information when it’s found to be proper. In order to give access to personal health information, it should be understood that all the rules and regulations applicable to access and disclosure of health information must be applied. It is part of the obligation of health information technicians to keep clients’ health information confidential, whether the information is transmitted verbally, on paper, or electronically. Therefore, you have to obey applicable laws and policies of the health institutions to which you are working for as HIT. 226 • • • • • • • • • • • • • • • • • • • • • • • • All health information is to be kept confidential unless the client authorizes the use and disclosure of personal information or it is specifically allowed by law. If the client is considered unable to give authorization, such as in the case of minors, a legal guardian should give the consent for release of information. When all requirements are fulfilled disclosure of health information will be limited to the minimum necessary to achieve the purpose of the disclosure. Use and disclosure of personal health information other than for the primary purposes can be possible in two cases. Firstly, personal health information can be disclosed or used when consent is acquired or collected from the client/patient. The second case or condition where personal health information disclosed is for his/her legal representative. In the former case, you may disclose or use individual health record by the consent of the client or to a person represented by the individual. In the latter case, there must be clear authorization from the law that you can use or disclose personal health information without the consent of the client. In addition, use and disclosure may be subject to notice and approval by the client, to a health professional regulatory body for the purpose of conducting investigations, discipline proceedings, practice reviews or inspections relating to the members of a health profession or health discipline. For example a health professional council or other regulatory body may see the record that is prepared by a doctor to examine its correctness or there may be mal practice or ethics complaint against this doctor. In this case the professional regulatory body may wish to examine the record documented by the doctor. Since the information on the record belongs to the client, in the case of disclosure the individual has a right to know to whom his/her information is given and for what purpose. The information recorded shall be retained by the custodian for a period of 10 years following the date of the disclosure. 227 • • • • • • • • • • • • • • • • • • • • • • • • • Patient access to their health information Clients have right of access to their own health information for different purposes. They may need to inspect copy or amend the information on the medical record when they believe they have wrongly provided inaccurate information. Under the draft regulation of HMIS, clients have the right to access their own health information. The client may access their records at any time they want in accordance with the policy of a specific health institution. This right may be exercised through a receipt of a copy or by viewing the health information in the medical record. In this case, the client is required to submit their requests in writing. If there is a form prepared for this purpose, ensure that the person is really the one who is the subject of the information. Because of the privacy and confidentiality implication of giving access, it should be done very carefully. This can be ensured by requiring the client to present an identification card and checking the information that belongs to the client. In the case of representation (where the client authorize another person to be given access to health information), if the client has signed a written authority for access to be granted to a person named in the instrument of agency, the person so named shall be given access to the health information requested. On the other hand a client who believes there is an error or omission in his individual health record may in writing or orally request, depending on the case, the custodian or health professional to correct or amend the record. Where the error concerns the client’s demographic data the health information technician may be of help. On the other hand, if the appropriate custodian or health professional agrees or refuse to make the correction or amendment in accordance with the relevant guideline, he shall make the correction or amendment or refuse the same and give notice to the client that the correction or amendment has been made or refused. 228 • • • • • • • • • • • • • • • • • • • • • • • Record Keeping during Refusal of treatment by Patients Patients have the right to refuse treatment and need to be made aware that they may refuse all or part of any care and treatment proposed and may withdraw previously given consent at any time. • Refusal may be written, verbal or by any form of communication possible. • It is also revocable at any time. • If there is any concern about the capacity of the patient to give valid consent, it should be discussed preoperatively with senior staff. Any remaining concerns should then be discussed with the Director of Medical Services or equivalent. Before complying with a direction to refuse or withdraw treatment, the health professional is required to take all steps to ensure that the patient has been provided with all relevant information; the patient has understood the information; and s/he has made an informed decision. Relevant information includes: • The nature of the illness • Any alternative forms of treatment that may be available • The consequences of those forms of treatment • The consequences of remaining untreated Medical records that clearly reflect the decision-making process can be pivotal in the success or failure of legal claims. In addition to the discussion with the patient, the medical record should describe any involvement of family or other third parties. If imminently or potentially serious consequences are likely to happen because of patient refusal, health care providers should make the refusal signed, witnessed and documented. 229 • • • • • • • • • • • • • • • • • • Self-check Assessment Activity: 1 Write down the common security measures Activity: 2 Elaborate the following concepts. a. Information Access b. Unauthorized Access _________________________________________________________________ ____________________________________________________________ c. Information Disclosure d. Information security Health Information system Principles for Service Delivery and Hospital Admission/ Discharge Procedures Learner module 134 Activity: 3 As part of the security measures, a health organization should develop and use policies and procedures related to health information handling of patients. What are the key points that the developed policies and procedures should address? Write the points using your own words. 230 • Activity: 4 • W/o Askale Taye is 50 years old patient, from Shashemane town, Admitted to Hawassa • Referral hospital for severe injury she sustained on her left leg. The surgeon decided to • perform amputation of the leg below the knee as the lower part of the left leg become • gangrenous (dead tissue). However, she refused the surgery and requested for discharge • from the hospital. As HIT of the hospital, what information elements (that has to be • recorded by the health care provider on here treatment refusal) should be checked for • completeness before her discharge is completed? 231 Hospital Admission and Discharge • • • • • • • • • • • Learning Objectives Upon completion of this topic, you should be able to: • Identify the content of admission\discharge recording tools • Demonstrate patient admission and discharging procedure • Describe patient information’s that should be recorded while admitting a patient • Monitor and update admitted patient medical record • Identify basic hospital statistics for inpatient services • Identify the content of discharge summaries • Explain patient discharge and clearance procedures • Verify patient’s medical records for completeness before filing 232 • • • • • • • • • • • • • • • • • • • • • • • • • • • • Hospital Admission Before we discuss the admission and discharge procedures, let us try to define terms related to admission and discharge process in a hospital. Outpatient (or out-patient): is a patient who is not hospitalized for 24 hours or more but who visits a hospital, clinic, or associated facility for diagnosis or treatment. Treatment provided in this fashion is called ambulatory care. Inpatient (or in-patient): is a patient "admitted" to the hospital and stays overnight or for an indeterminate time, usually several days or weeks. Treatment provided in this fashion is called inpatient care. Inpatients usually occupy a bed in a health care facility for at least four hours or overnight. The time needed before a person is declared an inpatient varies from country to country. In this regard, there is no written document in Ethiopia that specifies the time that should be spent in hospital before it is declared as inpatient. . The admission to a hospital involves the writing an admission note and it documents the patient's status, reasons why the patient is admitted for inpatient care, and the initial instructions for that patient's care. Patient’s leaving of the hospital is commonly termed as patient discharge, and involves a corresponding discharge note or summary. Where a patient is admitted on the expectation that he or she will remain overnight, but the patient dies or is discharged before the midnight census, the patient should still be regarded as inpatient, whether or not a hospital bed is occupied or treatment is provided. Such admission is commonly known as ‘admission for 24 hours observation’ in Ethiopia. Admission: Is a formal process whereby a person is accepted by a hospital for the purpose of hospital treatment as an inpatient. Bed management: is the allocation and provision of beds, especially in a hospital where beds in specialist department (wards) are a scarce resource. The "bed" in this context represents not simply a place for the patient to sleep, but the services that go with being cared for by the medical facility: Admission processing, physician time/visit, nursing care, necessary diagnostic work, appropriate treatment, and so forth. Health Information system Principles for Service Delivery and Hospital Admission/ Discharge Procedures Learner module 233 • • • • • • • • • • • • • • • • • • • • 137 Admission procedure The admission of a patient to hospital is ordered by a doctor and carried out by an admission clerk. At the time of admission, a patient already has a medical record number and medical record. Thus, a new number is not issued. The hospital, however, needs to keep a daily list of all admissions. All patients admitted, whether admitted for the first time or not and other admission related information on the appropriate recording tool. 8.4 Admission /Discharge recording tools With the reformed HMIS, there are three basic recording tools for inpatient services: The Admission/discharge card, Register and Tally. However, there are many clinical forms by which healthcare providers document the entire patient’s information captured during the inpatient stay of the individual. Our focus in this module will be introducing those card, register and tally sheets mentioned earlier. Other inpatient forms, on which most of the clinical events related to a patient are documented, will be summarized in the subsequent subtopic. Admission/discharge Card Admission / Discharge card is very useful recording tool of the patient’s information related to personal identification, ward admitted, admission diagnosis, discharge diagnosis, condition at discharge, admission and discharge dates and other financial information related to the inpatient services offered. 234 235 • • • • • • • • • • • • • Admission/Discharge Register The purpose of completing this register for each inpatient service is to gather information that enables the facility to identify top causes of morbidity and mortality of inpatient department. In addition, the data contained by the register helps to identify specific diseases or clinical conditions of priority that are targeted for eradication or control. The register is case register (not longitudinal register) where each row is used to record information of one patient Health Information system Principles for Service Delivery and Hospital Admission/ Discharge Procedures Learner module 139 admission and the same row will be completed at the time of discharge of that patient. It is located at all the wards (rooms where admitted patients receive inpatient services). The data to be filled in the admission/discharge registered is available in the medical records of each inpatient cases and it will be collected and entered at the time of admission and discharge each case. 236 • Content of Admission/ Discharge Register • The admission/discharge register has five basic groups of columns. These groups of related • columns are for identification, admission, provider initiated HIV testing and counseling • (PIHTC), discharge and finance information. • Identification includes: Medical Record Number (MRN), Age, and Sex, woreda / sub-city. • Admission includes: Date of Admission, Admission diseases classification (HMIS diagnosis) • PIHTC includes: HIV test offered, HIV test performed and HIV test result • Discharge includes: date of discharge, length of stay, condition at discharge and discharge • diagnosis (Based on HMIS disease classification) • Finance includes: Cost of service, Amount paid, and Voucher Number. 237 238 • • • • • • • • • • • • • • • • IPD Tally sheet: This tally sheet is important to summarize the inpatient services and diseases disaggregated by age group, sex and New/repeat status. It is filled by the care provider at the end of each day. Counts should be summed and state at the bottom the tally sheet at the end of each month. Health Information system Principles for Service Delivery and Hospital Admission/ Discharge Procedures Learner module 141 8.5 Information Recorded while Admitting a patient Most of the documents in the health record are clinical services and some of these clinical forms are discussed in the previous learner module 2 (Managing Medical Records). However, here we will try to describe and summarize the most important one as follows. I. History and physical examination recording form/patient form Function: To record patient history and physical examination findings. Location: Inside the Medical record folder Work process: When a patient is admitted as an in-patient a full history and physical examination should be conducted by the attending physician. 239 • • • • • • • • • • • • • • • • • • • • • • • • • II. Progress note Function: To record clinical findings and progress of the patient during the hospital stay. Location: Medical record folder Work process: When patient is seen by a clinician, the information obtained will be recorded with date, clinical details, and signature of the attending clinician. III. Nursing Process Forms • Nursing admission assessment form • Nursing problem statement list • Nursing care plan • Nursing patient progress report Function: To describe the nursing assessment, care plan and outcome of nursing care of an admitted patient. Location: Bed-side clip board during the patient’s stay, but must ultimately be included in the patient’s MR as part of the permanent record. IV. Medication Administration Record Health Information system Principles for Service Delivery and Hospital Admission/ Discharge Procedures Learner module 142 Function: To record all medications ordered and administered to a patient. Location: Bed-side clip board during the patient’s stay, but must ultimately be included in the patient’s MR as part of the permanent record. V. Fluid Balance Chart Function: To record all fluid inputs and outputs for patients at risk of fluid overload or dehydration. Location: Bed-side clip board during the patient’s stay, but must ultimately be included in the patient’s Medical record folder as part of the permanent record. 240 • • • • • • • • • • • • • • • • • • • VI. Consent forms Function: The consent form outlines the risks associated with a particular procedure. A signed consent form indicates that the patient (or designated proxy) has been informed of the risks and has authorized the procedure. Location: Medical record folder VII. Referral and Feedback Form (if relevant) Function: To document patient history at the hospital and to provide reason for referral Location: One copy in the Medical record folder and one copy to patient. 8.6 Monitoring and Updating Patient Information during patients hospital stay This part of managing medical record is entirely done during the inpatient stay of the patient. Main responsibility lay on the care providers involved in the treatment process of the patient. As described earlier, most of the clinical documents that constitute the medical records of Health Information system Principles for Service Delivery and Hospital Admission/ Discharge Procedures Learner module 143 inpatient cases are the clinical forms. The HIT has to check for the accuracy, completeness and on-time recording of these clinical forms on regular bases. The methods and the tools used to monitor and update these forms are similar to those medical records produced during the outpatient services as it is covered in the learner module of ‘Managing medical records’. 241 • Basic hospital statistics for inpatient services • Even though healthcare statistics is well covered in other learner module, it is important to • highlight the most important hospitals statistics required to monitor its performance. Each • relevant statistics are described by its name, definition and formula. • 1. Inpatient Death/mortality rate • Definition: A patient who expires/died while he/she is inpatient of a hospital. The term • ‘mortality’ is referred as death. It is a ratio of all inpatient deaths for a given period to the • total number of discharges and deaths in the same period. 242 • Inpatient death rate: • Total number of deaths of inpatient in a given period x 100 • Total number of discharges and deaths in the same period N.B Inpatient death rate should be calculated based on discharge data not admission data. • This is because a patient who is hospitalized has a chance of being discharged as died. 243 Number of IPD deaths cause meningitis case fatality rate Total number of admissions (dx : meningitis ) x100 244 Health System contd. D1.4. Admission rate. Number of inpatient admissions Admission rate x1000 Population in the catchment area Interpretation: • Admission rate reflects the interaction between demand and supply of inpatient care. • Like outpatient service utilization, admission rate is inversely related to certain barriers that may be physical (distance), economic (cost to patient), cultural (low awareness and health care seeking behavior) or technical (poor quality of health care). 245 D1.5. Bed occupancy rate (BOR). Definition: • The bed occupancy rate is the average percentage of occupied beds during the period under review (usually one year). Bed occupancy rate Number of patient bed - days Number of beds avaialable x Number of days in period Interpretation: • BOR reflects the level of utilization of inpatient services. • Inpatient services incur a high overhead. In Ethiopia hospitals consume more than 40% of public sector health funds. • Inpatient capacity that is greater than demand wastes resources. • A low BOR requires investigation. • A low BOR may also reflect low quality of service. 246 Health System contd. D1.6. Average length of stay (ALOS). Definition: • The average length of stay of patients in an inpatient facility during a given period of time. Average length of stay number of bed days Number of inpatient admissions Interpretation: • ALOS reflects the appropriate utilization of inpatient services. 247 • Average length of stay • Definition: a length of stay for one patient is the number of calendar days from admission to discharge. The average length of stay is the average of the sum of length of stay of any group of inpatients discharged during a specified period of time. 248 • Ave. Length of stay= Total inpatient service days of discharged (including deaths) Patients for a given period Total number of discharges and deaths in the same period Example: In June, a hospital has discharged 2,086 patients (including deaths, but excluding • newborns). • Their combined inpatient service days were 13 654 days. Using the above formula, the • average length of stay of these patients was: • = 13654 • 2086 • = 6.54 or 6.5 days • That is, the average stay as inpatient during June was 6.5 days. 249 • Bed occupancy rate • Definition: the percentage of inpatient beds occupied over a given period. To calculate the • bed occupancy rate for certain period, you need to know the number of patient days (also known as inpatient service day) which is a unit of measure of denoting the services received by one inpatient during one 24 hour period. A total patient day is the sum of all inpatient • service days for each of the days during a given period. 250 • Bed occupancy rate= Total number of patient days for a given period X 100 Available beds X the number of days in the period Example: Black lion hospital has 500 available beds and provided 13,250 patient days in • Hidar (November). Hidar has 30 days. The bed occupancy rate of the black lion hospital was: 13,250 x 100 88.3% 500x30 251 Case fatality rate • Definition: The case fatality rate is defined as the number of deaths assigned to a given cause (disease) in a certain period, divided by the number of cases of the disease reported during the same period. Case fatality rate of disease x = Number of deaths for a given disease y x100 Number of cases of the same disease reported y 252 • The number of days of care rendered to an inpatient is from admission to discharge. • The duration of an inpatient's hospitalization is considered to be one day if he is admitted and discharged on the same day and also if he is admitted on one day and discharged the next day. The day of admission should be counted but not the day of discharge. 253 Discharge and clearance procedures • • • • • • • • • • • • • • • • • The hospital discharge process is initiated on the recommendation of a physician. The process may vary from hospital to hospital as hospitals have their own policies regarding discharge. Patients should make sure they understand any follow-up instructions before leaving the hospital and, if not, they should ask for clarification. Possible questions they might need clarification on include: • Does the patient need a follow-up visit? Who should he/she see? Should the patient call to make the appointment or is it already arranged? • What medications have been prescribed? Are there any side effects? If there are, should the patient stop taking the medication? Medical record staff responsible for this procedure should be trained to ensure that the medical records are completed promptly and correctly. Completing Discharge Summaries A discharge summary is a summary of the patient’s stay in hospital written by the attending doctor. The minimum detail provided in a discharge summary is: • Patient identification • Reason for admission Health Information system Principles for Service Delivery and Hospital Admission/ Discharge Procedures Learner module 254 • • • • • • • • • • • • • • • • • • • • • • • • Examinations and findings • Treatments while in hospital and • Proposed follow up/ Death summary Upon the discharge a patient, the following information should be recorded on admission/discharge register entry that corresponds to the particular patient admission related information. • Date of discharge of the patient • Length of stay (the difference of data of discharge and date of admission) • Condition at discharge: the possible value can be improved or referred or dead left against medical advice or absconded (runaway from the hospital suddenly). • HMIS Diagnosis: Based on the HMIS disease classification. • Cost of the service: exact cost in terms of Birr. • Amount Paid: the amount of money paid for the service during stays and discharge (see figure 8.4). • Voucher number: from the payment receipt. Organizing Documentation of Discharged Patients While in hospital, the patient’s medical record develops with the recording of clinical information by doctors and other health professionals. Results of pathology tests etc. are added as they are received. Nurses record daily progress notes and special observations. If a patient has any special tests and/or surgical procedures, relevant information is included. On discharge/death of the patient the medical record, including all forms relating to the admission plus any previous records, should be sent to the Medical record unit as soon as possible or within 24 hours. 255 256 Admission/discharge service payment form. 257 • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • The discharge procedure begins with the receipt of the medical records of discharged patients/deceased. Health Information system Principles for Service Delivery and Hospital Admission/ Discharge Procedures Learner module 149 • The medical records of discharged client/deceases should be sent to the Medical Record Department by the ward staff on the same day of discharge/death or the next morning. In some countries, a staff member from the Medical record unit collects the medical records of discharged/deceased from the wards at a specific time every day. • The Medical record unit staffs are responsible for the daily bed census, which they receive from each ward at the beginning of the day. • From the bed census forms staff are able to record details of discharges and deaths and prepare a daily discharge list. This list is extremely important and should be duplicated and sent to a number of sections in the health care facility. 8.9 Verifying Medical Records for Completeness for discharged patient The Medical record unit staffs are responsible for managing the medical records of discharged patients and should check to see if they have all the medical records of discharged patients from the previous day. If any are missing they should contact the ward to find them. Once a patient has been discharged, the medical record should be returned promptly to the Medical Record Unit. Failure to do so may result in a missing medical record. Once the patient is no longer in the ward, their medical record can easily be misplaced. Medical record completion procedure begins with the receipt of the medical records of completed services, discharges and deaths. Those medical records should be sent to the medical record department by the health care staff by the end of the day and before that all the processes should be completed from each unit. In some cases, a staff member from the medical record unit collects the medical records from the health care facility wards every day. It is a good practice to list and send the summary of discharged and dead patient to the medical record unit. Health Information system Principles for Service Delivery and Hospital Admission/ Discharge Procedures Learner module 258 • • • • • • • • • • • • • • • • • • • • • • • The clerk in the medical record unit checks each medical record to ensure that all the forms are in the record. For example, if the patient has had an operation an operation report should be in the record. In addition all progress notes, pathology and x-ray forms, nursing notes etc. should be included. There should also be a final discharge note made by the attending doctor including to where the patient has been discharged and arrangements for follow-up. • The clerk then sorts the forms into the correct order (if they are not already sorted). In the case of new patient the forms are attached to a medical record folder with a clip or fastener. If the patient has been in health care facility before the old records are retrieved and the latest admission forms are added by placing them behind the appropriate divider or in a chronological order. • The clerk also needs to check if the doctor has completed the lower part of the front sheet. That is, the HMIS diagnosis has been recorded along with any other condition treatment while in the facility. • The signature of the health care provider is important as it shows that the doctor has completed the medical record and takes responsibility for the content. Returning Patient Document to MRU The Medical Record of discharged patients or the deceased should be returned to the Medical Record unit within 24 hours of discharge. The Medical Record unit should review the Medical Record to see if all forms have been properly signed, particularly the discharge summary. If they are not signed, the Medical Record Department should alert the physician on record or case team leader to complete and sign the discharge summary 259 • Self Check Assessment • Activity: 1 • Describe the following concepts and hospital statistics • a. Admission • b. Inpatient • c. Wards • d. Discharge Summary • e. Average length of stay • f. Bed occupancy rate 260 • • • • • • • • • • • • • • • Activity: 2 In May, 2012, the total number of discharged client at Zewditu referral Hospital have added up to 2,086 patients (including deaths, but excluding newborns).Their combined inpatient service days were 13, 654 days. What is the average length of stay of these patients? _________________________________________________________________ ___________________________________________________________________ Activity: 3 Write down relevant information included in patient discharge summary. _____________________________________________________________________ Activity: 4 Who decide to discharge patient from a hospital? _____________________________________________________________ _____________________________________________________________ Health Information system Principles for Service Delivery and Hospital Admission/ Discharge Procedures Learner module 153 261 • • • • • • • • • • • • • • • Activity: 5 W/o Selamawit is a 45 years old female who sustained injury to her left shoulder and admitted at Dessie referral Hospital. Her physician performed physical examination and requested for x-ray of the shoulder joint area. Her physical assessment and radiological examination reveals a fracture and dislocation of the shoulder joint. After six weeks of inpatient treatment, her condition was improved and was discharged from the hospital, then after; a discharge summary was prepared and signed. Finally, the health information technician checked her medical record while returning to the medical record unit for filing. Unfortunately her radiology report sheet and physical examination sheet were missed from the chart. a. How do you handle the missing document? Explain the steps involved with your own words. _____________________________________________________________ b. Who will be responsible for the missed document? How do you correct this documentation problem? 262