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TA for Capacity Building for Tertiary Care Services An EU-funded project managed by the European Agency for Reconstruction

Republic of Serbia

!"!STR# $% &EA'T&

Day Surgery/ Day Hospital (

Challenging e)isting models of service deliveryin a transitional country

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EAR/EU SOFRECO e!"#i!al Assista#!e$ A ea%, &elgra'e( Cli#i!al Ce#tre o) Ser*ia, &elgra'e(( Cli#i!al Ce#tre o) +o -o'i#a, o-i Sa'((( Cli#!al Ce#tre o) i(((( Cli#i!al Ce#tre o) 0ragu e-a!

http://sr.wikipedia.org/sr-el/%D0%A1%D0%BB%D0%B8%D0%BA%D0%B0:Coat_of_arms_of_Serbia_small.svg

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Conte)t5 4ay Surgery64ay &ospital models of service delivery are

in their early stage in Serbia75 The health reform targets call for 8-9: annual increase

in ambulatory services7

5 The EU6EAR 2roject provided to the inistry of &ealth-o& has been charged ;ith < reforming tertiary care services and < implementing an E!B loan of EUR =>> in the beneficiary

institutions( the Clinical Centres in Belgrade+ "ovi Sad+ "is and*ragujevac for their rehabilitation and strategic development7

5 %our largest university hospitals in Serbia together have < over ==>+>>> inpatients < ?=>+>>> surgeries annually < rather lo; day surgery6day hospital cases rates7

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!nternational surveys < Country benchmar s for daysurgery activity

5 !nternational Association for Ambulatory Surgery @$EC4

5 Results of orld ide 4ay Surgery Activity =>>8 < ? countries or regions+ 8 procedures < !n most countries day surgery activities are ;ithin public

hospitals D!n USA ;here activity is very high+ the percentage of private free standingunits is also very high

<Reimbursement systems are very different < USA+ Canada and Scandinavian countries have highpercentage of day surgery procedures

< Countries having high rate of day surgery in some specialtiesmay have significantly lo; rate in other specialties

Bac ground

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!nternational variations in availability and diffusion of day surgery

icro level < 2atients or physicians may not ;ant+ or may not be able to

use day surgery < &ospital characteristics+ such as the number of hospital beds

acro level <

&ealth care system characteristics+ such as financing andinsurance influence the shift to day surgery

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0ey )a!tors to Co#si'er as Care S"i)ts to Day Surgery 1 Outpatie#t

Cost

!ncreased supply+technology costs

'ength-of-staycost savings

2ayer %i3

&ealth!nsurancecoverage

A#!illaryDe%a#'

Related billablevolume

I%pa!t o)Co%petitio#

2rivatephysician offices

Market 4ro5t"2ote#tial

!mprove $utcomesReduced ris and

pain

Bac ground

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Slo5 2a!e o) Cli#i!al 2roli)eratio#

e!"#ology$Dri-e# Outpatie#t 4ro5t"

6778

2er!e#tag

eOutpatie#t

78

i%e

Bac ground

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Bac groundre#' i# take up o) 'ay surgery

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Bac ground5 Even ;hen the e-i'e#!e )or !"a#ge to !li#i!al pra!ti!e is so stro#g

a#' see%i#gly sel) e-i'e#t + there is no guarantee that it ;ill beadopted7

5 This is a classic management of change issue that involves < 9so)t: )a!tors such as professional attitudes

< 9"ar': )a!tors such as data 6 resources 6 appropriate fundingsystem from the &ealth !nsurance %und - &!% as an incentive for thischange7

5 Currently+ HIF )u#'s t"e "ospital *ase' o# a 9"ospital 'ay: andtherefore operating budget disincentives to FshiftG to day surgery

because the &!% ;ill not reimburse the hospital for a day case7

5 This causes certain 'e-iatio#/a' ust%e#ts i# re!or'i#g/i#-oi!i#g ofthe day surgery cases to;ards the &!%+ resulting in lo;er rate ofrecorded day surgery cases that have really been performed

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ethods

5 $ver past seven years+ the Clinical Centres have still beenoperating under < unchanged legislation < unchanged model of service delivery < fi)ed operating budgets

5 These represents limitation for the hospitals to respond toincreasing demands of emerging ambulatory servicedelivery model7

5 The EU6EAR 2roject is a vehicle ;ith capital investmentsproviding an opportunity <

to restru!ture spa!e for more day surgery and day hospital < to )a!ilitate pro)essio#als *uy$i# to this model of service delivery < to %oti-ate MoH to support this change due to systemic

i%pro-e%e#t i# ;uality o) !are a#' lo5eri#g !osts < to i#)lue#!e MoH a#' HIF to !"a#ge )i#a#!i#g %o'els.

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5 A!!o%%o'atio# )or 'ay surgery < ost cost-effective option is a self-contained day surgery unit+ ;ith its o;nadmission suite+ theatre and recovery area together ;ith administrative

facilities7 < 'ess satisfactory arrangement is a day case ;ard ;ith patients going to

the main operating room

5 Ma#age%e#t o) t"e 'ay surgery u#it < 4ay surgery needs a rigorous management structure including

5 lead clinician5 day surgery manger6senior nurse5 other staff

5 C"a#ges o) 5orki#g pra!ti!es < Specific training for the surgeon and anesthetist in day surgery techniHues

5 'ocal incentives+ such as the availability of enhanced resources to those ;hoshift treatment to day surgery

5 4edication of theatres for day case are preferred for better output+ compared totheatre6;ard mi) ;ith inpatient surgery

< The advantages to patients5 $pportunities to see and e)perience day surgery

ethods - Orga#i

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Resear!" 5it"i# t"e Cli#i!al Ce#ters

5 Research ;as conducted as < Hualitative Huestionnaire of staff < Huantitative6Hualitative measurement of operating facility utiliIation

5 Research covered < ??= operating theatres < over t;o ;ee s period < analyIing over 8>>> surgical interventions

5 Jualitative Huestionnaire Danonymous ;as distributed < among top and medium management in all K Clinical Centers < covering 8=> managers of different level

ethods

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Results 5 !t is an internationally accepted standard that >: of elective surgery

cases can be underta en in day setting75 !n =>> + specific annual targets for =9 selected procedures that can

be done safely and effectively as day cases ;ill be set in a step-;isefashion7

5 Results of the survey < There is #o )or%ali

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Results5 "ere is a pote#tial to !arry out more day surgery and elective operations

;ithin current resources by < redistributing and dedicating theatres < improving scheduling

5 reducing cancellations5 decreasing gaps bet;een patients

< improving the management of e)isting theatre resources7

5 Ho5e-er < There is no functional scheduling and reporting system for utiliIation < There is no theatre6;ard boo ing system prior to admission of patientsM < There is no measurement of utiliIation of operating facilitiesM <

embers of $R teams are not fully trained for day surgery ;or flo;5 Still

< There is evidenced increase in day surgery in Serbia from =>>=7 < Thorough Action plan must be implemented in order to reach targets in day surgery

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$bservation by hospital staff forimprovements needed in development

of day surgery

5 Space5 EHuipment5 Change of financing pattern5 Training and education of manpo;er 5 !mprovement of recording6measurement procedures

Results

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Results

5 ,iven their magnitude and high case-load+four largest university hospitals in Serbia

offer a large area for improvement < in Huality of care < decreasing hospitaliIation rates and A'$S

< increasing patient satisfaction < decreasing cost per patient7

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Results

5 !n each Clinical Centre or ,roups for 4ay Surgery 64ay &ospital ;ere formed to < analyIe their e)isting service delivery model and

patient flo;s to be able < to meet the o& target of average 8-9: annual

increase in ambulatory care75 Some preliminary models of activity-based financing ofday procedures such as < chemotherapy < cataract procedures < pace-ma ers < cardiac catheteriIationsare already in place7

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Conclusions

5 4efining procedure-specific annual percentage rates onthe five year period D=>> -=>?= basis

5 4eveloping an implementation plan ;ith different targetsfor each of the =9 potential day cases have been doneDeg7 8>: of cataract e)tractions and =>-8>: of herniarepairs as day cases in the first year +

5 entioned should secure sustainable shift to;ardsambulatory care model7

TA for Capacity Building for Tertiary Care Services An EU-funded project managed by the European Agency for Reconstruction