jandacva, jandacvis momsaxureba da xarisxi
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jandacva, jandacvis momsaxureba da xarisxi. 2011 lopota. cnobili adamianebi sazogadoebrivi jandacvis Sesaxeb. “ araferi ar SeiZleba iyos qveynisTvis imaze mniSvnelovani, vidre jandacvaa; qveynis umTavresi sazrunavi unda iyos misi xalxis janmrTeloba ” - PowerPoint PPT PresentationTRANSCRIPT
jandacva, jandacvis momsaxureba da xarisxi
2011
lopota
cnobili adamianebi sazogadoebrivi jandacvis Sesaxeb
“araferi ar SeiZleba iyos qveynisTvis imaze mniSvnelovani, vidre jandacvaa; qveynis umTavresi sazrunavi unda iyos misi xalxis janmrTeloba”
franklin d. ruzvelti
(In a report to the New York Legislature, 1931)
dRes visaubrebT1. xarisxTan dakavSirebuli problemebi jandacvis sistemaSi;2. ra aris samedicino Secdoma, Secdomis tipebi3. ra aris jandacvis xarisxi – ra aris pacientis usafrTxoeba4. xarisxis gansazRvrebebi5. xarisxTan dakavSirebuli problemebis analizi ekonomikuri kuTxiT6. mTavrobis roli jandacvis sistemaSi xarisxis uzrunvelsayofad7. xarisxis gasaumjobesebli miznebi 8. ra aqtivobebia saWiro xarisxis gasaumjobeseblad
anu jandacvis politika xarisxTan mimarTebaSi
ra aris janmrTeloba?
“sruli fizikuri, mentaluri da socialuri keTildReoba da ara ubralod
daavadebis an sisustis ararseboba”
(WHO Constitution)
janmrTelobios koncefciaMarc Lalonde
1. definicia – janmrTeloba es aris faqtorTa rezultati, romlebic asocirebuli arian genetikur memkvidreobasTan, garemosTan, individualur cxovrebis wesTan da samedicino momsaxurebasTan. janmrTeli cxovrebis xelSewyobas SeuZlia gaaumjobesos janmrTeloba da Seamciros samedicino momsaxurebis saWiroeba
2. elementebi – a. genetikuri da biologiuri faqtorebi; b. qceviTi (cxovrebis stili) faqtorebi; g. garemo (moicavs ekonomikur socialur da fizikur faqtorebs); d. jandacvis sistemebis organizacia
jandacva
jandacva es aris kerZo da saxelmwifo seqtorebis saSualebiT sruliad
sazogadoebis mcdeloba miRweul iqnas janmrTeloba
jandacvis sistemis amocanebi
• gaaumjobesos mosaxleobis janmrTelobis mdgomareoba;
• akontrolos jandacvis xarjebi;
• prioritetebis mixedviT gadaanawilos arsebuli resursebi;
• gaaumjobesos momsaxurebis xarisxi;
• gadaanawilos momsaxureba Tanabrad mosaxleobis yvela fenaze
mTavari amocana
uzrunvelyos mosaxleoba adeqvaturi samedicino momsaxurebiT
Aadeqvaturi samedicino momsaxureba
ras vgulisxmobT adeqvatur momsaxurebaSi?A
adeqvaturi Careva niSnavs, roca im maqsimaluri saSualebiT rac konkretul Carevas SeuZlia
miRebuli sargeblebi (gazrdili sicocxlis saS. xangrdzlivoba, tkivilis Semcireba fsiqo emociuri, sxva funqciuri gaumjobeseba) aRemateba mosalodnel negatiur
rezultatebs (sikvdiloba, avadoba, dakarguli samuSao saaTebi, tkivili da a. S)
Chassin MR, Park RE, Kahn KL, Kosecoff J
samedicino xarisxi
• The Institute of Medicine (IOM) -xarisxi romliTac jandacvis servisebi
Tanamedrove profesiuli codnis saSualebiT zrdis sasurveli Sedegebis miRwevis albaTobas
Department of Health (UK 1997)
jandacvis xarisxi aris:
• swori qmedebebi (ra)
• swor pirovnebebze (vis)
• swor dros (rodis)
• Dda swori qmedebebi pirvelive Carevisas
maRali xarisxis jandacvis politikis safuZvlebi
1. pacientcentruli momsaxureba;
2. adeqvaturi xelmisawvdomoba;
3. adeqvaturi samecniero codna;
4. kompetenturi jandacvis mimwodeblebi;
5. samedicino da finansuri gadawyvetilebebis gamijvna;
6. jandacvis sistemis swori organizacia (efeqtianoba, efeqturoba, swori sakanonmdeblo uzrunvelyofa);
jandacvis evolucia:
daavadebis mkurnalobidan jandacvamde
1980 1985 1990 1995 20001975 2005
xarjebis kontrolis era
xarjebis Semcirebisa da
utilizaciis kontrolis era
xarisxze orientirebuli medicinis era
ratom xarisxze orientirebuli era
xarisxi - kliSe
amerikis medicinis institutis moxseneba
im samedicino Secdomebis gamo, romelTa prevenciac SesaZlebeli iyo yovelwliurad
amerikaSi iRupeba ufro meti adamiani vidre Sidsisagan, ZuZus kibos an avtokatasrofebisagan
saSualod 98 000 – 100 000adamiani weliwadSi
IOM Report 1999.
samedicino Secdomebis zegavlena
• didi britaneTis jandacvis departaments 2000 wlis moxsenebaSi iTqva, rom ubeduri SemTxvevebi xdeba hospitalizirebuli pacientebis daaxloebiT 10 %-Si anu 850, 000 ubeduri SemTxveva wlis ganmavlobaSi.
• “xarisxi avstraliis jandacvis sistemaSi” kvlevis mixedviT (romelic gamoica 1995 wels) ubedur SemTxvevaTa sixSire hospitalizirebul pacientebSi 16.6 % Seadgens.
• The Hospitals for Europe’s Working Party on Quality Care in Hospitals daadgines, rom evropaSi 2000 wels yoveli meaTe hospitalizirebuli pacienti ziandeboda iseTi dazianebebisgan, romlis prevenciac SesaZlebeli iyo;
ra aris Secdoma
Secdoma aris dagegmili moqmedebis ar Sesruleba ise, rogorc winaswar iyo
gansazRvruli…an Sedegis misaRwevad arsowori gegmis
gamoyeneba
Secdomis tipebi
• aqtiuri
• latenturi
HealthGrades moxseneba - daskvna
• sikvdilobis umetesoba gamowveulia ara personalis arakompetenturobis, aramed sistemuri Secdomebis gamo
• adamiani yovelTvis uSvebs Secdomas ara aqvs mniSvneloba Tu rogori ganaTleba da momzadeba aqvs mas……
rogoria industriuli standarti Secdomebis dasaSvebi min. raodenoba
• A230 – ze naklebi (wuni, defeqti) 1 milion warmoebul produqtSi anu 0,023%
• 5 –ze naklebi yovel 1 milionSi Secdomebi dakavSirebuli finansuri servisebis tranzaqciebTan anu 0,0005 %
• ra xdeba jandacvaSi?
ra xdeba jandacvaSi
6,000 dan 300,000 mde xarvezi, yovel 1 mlnSi
Sesabamisad 0,6 – 30%
Source: Kohn, LT, Corrigan, JM, and Donaldson, MS (Eds).
ubedur SemTxvevaTa da SecdomaTa sixSire
370 sxva adgilas Catarebuli qirurgiuli operaciebis SemTxvevebi;
365 operaciuli/post-operaciuli garTulebebi;326 wamlismier SecdomebTan dakavSiebuli
SemTxvevebi;221 sikvdili dakavSirebuli mkurnalobis
dayovnebasTan;144 pacientis dacema/waqceva;124 sikvdiloba patimrobaSi myof pacientebs
Soris107 Zaladoba/gaupatiureba/mkvleloba85 gadasxmasTan dakavSirebuli movlenebi84 perinataluri sikvdiloba/dazianeba57 infeqciasTan dakavSirebuli movlenebi57 saavadmyofodan gaqcevis Semdgomi sikvdili51 xanZari49 anesTeziasTan dakavSirebuli movlenebi
erTiani komisiis mier ganxiluli 2966 ubeduri SemTxveva, ianvari 1995 - dekemberi 2004:
ubedur SemTxvevaTa adgili/dawesebuleba
ianvari 1995 – dekemberi 2004
0 200 400 600 800 1000 1200 1400 1600 1800 2000
Office-base surgery
Health care network
Critcal access hospital
Clinical laboratory
Home care service
Ambulatory care setting
Long term care facility
Emergency department
Psychiatric unit
Out-pt behavioral health
Psychiatric hospital
General hospital
Total for all settings = 2966
1942351
159
155
131
95
67
54
6
2
1
3
ubedur SemTxvevaTa ZiriTadi mizezebi
0 10 20 30 40 50 60 70 80 90 100
Organization culture
Care planning
Continuum of care
Leadership
Environ. safety / security
Procedural compliance
Competency/credentialing
Availability of info
Staffing
Patient assessment
Orientation/training
Communication
yvela kategoria; 1995-2004
Percent of 2966 events
sikvdilis SemTxvevebi drois erTeulSi - riskebi
• orsuloba 1• matarebliT mgzavroba 5• saxlSi muSaoba 8• soflis-meurneobis nawilSi muSaoba
10• • sacobSi yofna 50
• mSeneblobaze muSaoba 67• frena 100• hospitalizacia 2000
cudi xarisxis Rirebuleba
cudi xarisxis wliuri xarji saS. TiTo dazRveulze
• $1,500 pirdapiri jandacvis xarji
• $400 - $750 arapirdapiri xarji (mag gacdenili samuSao dReebi)
• $1,900 - $2,250 cudi xarisxis MmTliani jamuri saS. xarji
jandacvis da cudi xarisxiT gamowveuli xarjebis dinamika wlebis mixedviT
0,25
0,7
2,3
0,07
0,2
0,42
0,69
1,4
0
0,5
1
1,5
2
2,5
1980 1990 2001 2008
jandacvis xarjebi sul
cud xarisxTan asocirebuli xarjebi
cudi xarisxis efeqti Juran Institute, Inc.
The Severyn Group, Inc. 2007
problema efeqti
1 wamlebis araswored gamoyeneba 300 mlrd
2 antibiotikebis araswori daniSvna 5 mlrd
3 nozokomialuri infeqciebi 20-60,000 sikvdilis SemTxveva + 18 mlr
4 diabeti 132 mlrd
5 depresia 80 mlrd
6 araadekvaturad namkurnalebi gulis mwvave iSemiuri daavadebebis sikvdilobis SemTxveva yovelwliurad
18, 000 sikvdilis SemTxveva
7 arasworad marTuli gripisa da pnevmokokuri vaqcinacia
10,000 - 20,000 sikvdilis SemTxveva
8 asTmis cudi marTva 18 mlrd
9 gulis qronikuli iSemiuri daavadebebis uxarisxod marTva
10 – 40 mlrd
cudi xarisxis gamovlinebebi
• resursis zedmetad moxmareba
• resursis arasakmarisad gamoyeneba
• resursis arasworad gamoyeneba
resursis zedmetad gamoyeneba
• qirurgiuli procedurebi, testebi, samkurnalwamlo saSualebebi:
• mag: histereqtomiebi, kardiokaTeterizaciebi, timpanostomiebi, karotiduli endarteqtomiebi, kardialuri peismeikerebi, gstrointestinaluri endskopiebi, antibiotikebi, sedatiuri saSualebebi, arasteroiduli anTebis sawinaaRmdego saSualebebi
resursis zedmetad gamoyenebis mizezebi:
kvlevebi uCveneben
• zedmeti raodenobis hospitlebi – hospitaluri servisebis rigi procedurebisa da mkurnalobis zedmetad gamoyeneba,
• zedmeti raodenobiT eqimebis Tavmoyra garkveul regionSia aseve mizezia zedmeti moxmarebis da jandacvis xarjebis zrdis
resursis arasakmarisad gamoyenebis magaliTebi
• bevria faqtebi, rom eqimebi ar mihyvebian mtkicebulebebze dafuZnebul gaidlainebs da pacientebi ar iReben diagnostikur da Teerapiul servisebs, wamlebs da procedurebs iseTi daavadebebis dros rogorebicaa g.i.d da diabeti;
• gripis da pnevmokouri vaqcinebis administrireba;• skrining testebi depresiis, ZuZus kibos, qlamidiazis
dasadgenad
rac iwvevs sicocxlis xarisxis daqveiTebas da rig SemTxvevaSi sikvdils.
aseTi midgomebis zusti finansuri Sedegi ar aris naTeli
resursis araswori gamoyenebis magaliTebi
• samedicino Secdomebi yvelaze metad xdeba arasworad gamoyenebis dros:
• wamlebi;• nozokomialuri infeqciebi;• diagnostikuri da qirurgiuli Secdomebi;• samedicino aparaturis araswored
gamoyeneba
• erTi ver SesZlebs garantirebuli gaxados xarisxi – erTs SeuZlia mxolod gazardos albaToba, rom momsaxureba iqneba “kargi” an “ukeTesi”
• Avedis Donabediani
• saWiroa sistemuri midgoma
jandacvis xarisxis struqtura avedis donabedianis mixedviT
struqtura procesi Sedegi
kapitaluri Senobebi, aparatura,
saSualebebi trenirebuli samed. personali (eqimebi,
eqTnebi, administratorebi)
adekvaturi, efeqturi, eTikurad
relevantuli, koordinirebuli da
socialurad misaRebi
samedicino momsaxureba
sikvdiloba, avadoba, cxovrebis xarisxi,
pacientTa kmayofileba
sistemis maxasiaTeblebi Ppacientis maxasiaTeblebi
source: Hopkins: Measuring the quality of medical care, Royal College of Physicians of London, 1991
saxelmwifos roli
jandacvis Tavisufali (araregulirebadi) bazari
iwvevs uTanabrobas, gazrdil xarjebs
sazogadoebisaTvis da sabolood xarjebis zrdas
mTavrobisaTvis
kerZo seqtori kontrolis (regulaciis) gareSe ar iqneba farTo sazogadoebis interesebis dacvaze pasuxismgebeli
da
jandcvis bazari ar aris srulyofili da idealuri
Sesabamisad…
ra aris idealuri bazari?
• Zalaufleba Tanabaria• idealuri konkurencia da arCevani• sruli informacia• fasebi ar aris fiqsirebuli• gamWvirvalea Semsyidvelisa da
gamyidvelisaTvis
ratom aris jandacvis bazari arasrulyofili (idealuri)?
• urTierToba momxmarebelsa da mimwodebels Soris ar aris Tanabari
• mimwodebels gaaCnia meti informacia
• momxmarebeli ar aris srulad informirebuli
• momxmarebeli xSirad krizisSia da damokidebulia mimwodebelze
• alternatiuli miwodebis resursi xSirad ar aris SesaZlebeli
• mimwodeblebs xSirad SeuZliaT fasebis gayinva
• mesame piris gadamxdelis (dazRveva) stimulebi cvlis mimwodeblis da momxmareblis gadawyvetilebebs
ra unda gaakeTos qveyanam
pacientis usafrTxoebis mxriv ?
saxelmwifom xeli Seuwyos
usafrTxo sistemis Seqmnas
• Poka – Yok
• 6 Sigma
erovnuli nabijebi pacientis usafrTxoebis gaumjobesebisaTvis
• usafrTxoebaze fokusirebuli standartebis SemuSaveba
• Secdomebis Setyobinebis xelSewyoba• gamocdilebis gaziareba• riskis Semcireba prevenciis gziT• pacientebis usafrTxoebaSi CarTva• usafrTxoebis yovelwliuri miznebis
SemuSaveba• TavSeyra, TanamSromloba, ganaTleba
• imisaTvis, rom uzrunvelyos xarisxi jandacvis sistemaSi
• saxelmwifos erTerTi mTavaria funqciaa areguliros jandacvis bazari
sistemis martivi xedva
rogor gavaumjobesoT
rasac vakeTebT?
ratom vakeaTebT
rasac vakeTebT?
rogor vakeTebT
rasac vakeTebT
jandacvis regulacia
• 1970 iani wlebi mimowodeblis qcevis maregulirebeli decentralizirebuli programebi (jandacvis saagentoebi, saWiroebis serTifikatebi, biujetebi)
• 1980 iani wlebi metad centralizirebuli regulaciebi (peer review organizaciebi, samedicino praqtikis gaidleinebi) da biujetebi (medicare biujeti, prospeqtuli)
• gaZlierda qceviTi regulaciebis saxiT naklebad biujeturi regulaciebi
jandacvis regulacia II
• yvela dasavluri qveynebi aregulireben TavianT jandacvis sitemebs;
• yvela (amerikis garda) aRiarebs saWiroebas centraluri mTavrobis mier myari magram naTeli wesebis dawesebas Semsyidvelebis, mimwodeblebis da momxmareblebisTvis;
• yvelas esmis, rom mesame piris gadaxdisa da exstensiuri benefitebis kombinacia sxva SSesaZleblobas ar izleva.
jandacvis regulacia III
• umetesi dasavleTis qveynebi strategiul aqcents akeTeben biujetur regulaciebze (SeTanxmebuli fee eqimebTan, globaluri biujeti saavadmyofoebs. es sazogadoebebi naklebad arian damokidebuli qceviT regulaciebze
• qceviTi regulaciebi zemoqmedebs ekonomikur aqtivobebze da Sesabamisad biujetze, da biujeturi regulacia SesaZlebelia iyos efeqturi mxolod im SemTxvevaSi Tu is zemoqmedebas axdens qcevaze
• gansxvaveba aris intervenciis strategiaSi aseT SemTxvevaSi
• aSS –Si 1980 iani wlebidan gamoCnda biujeturi regulaciebi arsenali
• aris molodini, rom iqneba seriozuli cvlileba am mimarTulebiT
Tumca
P4P moqmedebaSia
maregulirebeli midgomebi
• licenzireba
• serTificireba
• akreditacia
Llicenzireba
mTavrobis mier marTuli savaldebulo programa, romelic moiTxovs, rom:
samedicino dawesebulebebi akmayofilebdnen minimalur samoqmedo standartebs
serTificireba
nebayoflobiTi samTavrobo an arasamTavrobo programa, romelic aRiarebs, rom:
samedicino dawesebulebebi akmayofileben garkveul standartebs specializirebul
mimarTulebaSi.
umetesad nebayoflobiTi procesi, romliTac samTavrobo da
arasamTavrobo organoebi aniWeben aRiarebas im samedicino
dawesebulebebs, romlebic akmayofileben garkveul
standartebs, romelic moiTxovs uwyvet struqturul, procesualur da
Sedegobriv ganviTarebas.
akreditacia
es aris moTxovnebi, romlebic gansazRvraven Sesrulebis
molodinebs struqturis, procesis da Sedegis gaTvalisiwnebiT. unda arsebobdes organizaciaSi, raTa
uzrunvelyofili iyos pacientis usafrTxoeba da movlis xarisxi.
standartebi
I. pacientcentruli momsaxureba
• pacientis/mosaxleobis (saWiroebebis Seswavla/gaTvaliswineba);
• pacientis uflebebis dacva;
• eqimis da pacientis urTierTobebis gaumjobeseba (imijis gamosworeba);
• pacientis ganaTleba
• momxmareblis maqsimaluri CarTva gadawyvetilebis miRebis procesSi
II. adeqvaturi xelmisawvdomoba;
• geografiuli;
• finansuri (bazisuri kalaTa);
• xarisxobrivi (adeqvaturi);
• Tanasworoba (eTnikuri, genderuli, profesiuli).
III. adeqvaturi samecniero codna;
• sarwmuno samecniero kvlevebis warmoeba;
• statistikuri meTodebis aqtiuri danergva samedicino sazogadoebaSi;
• sarwmuno literaturis gamoyeneba;
• samecniero mtkicebulebebze dafuZnebiT gadawyvetilebebis miRebis praqtika
IV. kompetenturi jandacvis mimwodeblebi;
• prediplomuri ganaTleba;
• postdiplomuri ganaTleba;
• licenzireba, akreditacia (dawesebulebebis);
• mimwodebelTa Sefasebis Tvladi kriteriumebis SemuSaveba;
• uwyveti samedicino da profesiuli ganaTleba;
• dawesebulebebis, medpersonalis optimizacia.
V. samedicino da finansuri gadawyvetilebebis gamijvna;
• samedicino dawesebulebaTa da med. personalis dafinansebis gamarTuli politikis SemuSaveba;
• swori motivaciuri sistemis SemuSaveba;
• klinikuri da kliniko-ekonomikuri standartebis Camoyalibeba
VI. jandacvis sistemis swori organizacia (efeqtianoba,
efeqturoba);• axali struqturuli erTeulis Camoyalibeba
• saxelmwifo, naxevrad saxelmwifo Tu decentralizebuli modelebis ganxilva;
• multiseqtoraluri kolaboraciis uzrunvelyofa;
• mkafiod gansazRvruli pasuxismgeblobebis Camoyalibeba;
• samedicino momsaxurebis balansireba pirvelad moereul da mesameul rgolebs Soris;
• marTvis informaciuli sitemebi;
• adeqvaturi mmarTvelobiTi gundebiT samedicino dawesebulebaTa uzrunvelyofa;
• samecniero mtkicebulebebze dafuZnebuli marTvis praqtika
xarisxis gaumjobesebis meTodebi modeli I
finansuri stimulireba:
1.1 pirdapiri finansuri stimulebi mimwodebels kargi xarisxisTvis
1.2 rogorc saukeTeso mimwodeblis saxalxo aRiareba
1.3 momxmareblis finasuri stimulireba ukeTesi xarisxis arCevisaTvis
1.4 xarisxTan dakavSirebuli aqtivobebis subsidireba
modeli #2
seleqtiuri kontraqtireba saukeTeso maCveneblebis mqone mimwodebelTan
2.1 kontraqtiT gansazRvruli ufleba movaleobebi
2.2 Sesrulebis kriteriumebis danergva2.3 saukeTeso centrebis aRiareba – referens
centrebad qceva, seleqtiuri kontraqtireba
modeli #3
regulirebis sxva saSualebebi,
3.1 mimwodebelTa qcevis regulacia (licenzireba uwyveti samedicino ganaTlebisa da profesiuli ganviTarebis CarTviT). Tanamedrove klinikuri gaidlainebisa da protokolebis danergva;
3.2 struqturis gaumjobesebis xelSewyoba, dawesebulebaTa gamkacrebuli standartebis da axali kriteriumebis danergviT
3.3 procesis xelSewyoba akreditaciis procesis danergviT
gamWvirvaloba
sikvdiloba saavadmyofoebis mixedviT
saavadmyofoSi Semobrunebis maCvenebeli
barZayis motexilobis gaTuleba
sakeisro kveTa saavadmyofoebis mixedviT
instruqciebi gawerisas
Tambaqos sawinaaRmdego kampania saavadmyofoSi
didi madloba