1、1,Chapter 1: Health Care Delivery Systems Feipei Lai National Taiwan University,2,Health Care Delivery Systems,History of Medicine and Health care Delivery Continuum of Care Health Care Facility Ownership Health Care Facility Organizational Structure Licensure, Regulation, and Accreditation,3,Introd
2、uction,Health care delivery has been greatly impacted by escalating costs, resulting in medical necessity requirements, review of appropriateness of admissions, and requirement for administration of quality and effective treatments.,4,MRXO,在臨床醫學中，進行手術時同時使用磁振造影並整合各種影像技術是目前最熱門的醫療概念。新式的未來手術室中，安裝有全球首套MR
3、XO解決方案，即完全整合磁振造影(MR)、光及電腦斷層掃描(CT)系統，大幅減少病患危險並簡化醫師的手續，可望提高手術成功率。 這項由日本東海大學、飛利浦醫療系統事業部合力推動的未來手術室，已經由日本東海大學的松前教授、津具醫師、山本醫師共同在手術室同時使用MR(磁振造影)和X光影像技術，來進行神經外科手術。,5,MRXO,在未來手術室中執行手術，可依執刀醫師與病患狀況，在數分鐘內將病患從手術台搬移到磁振造影、電腦斷層掃描或光診斷系統，增加手術精密度與成功率。在磁振造影和電腦斷層掃描區域有拉門。,6,History of Medicine & Health Care Delivery,Hist
4、ory of medicine Evolution of health care delivery in the United States,7,History of medicine,In 1994, scientists discovered the genes responsible for many cases of hereditary colon cancer, inherited breast cancer, and the most common type of kidney cancer.,8,Evolution of health care delivery in the
5、United States,1991 The Workgroup on Electronic Data Interchange (WEDI) was created to reduce health care administrative costs through implementation of the electronic data interchange (EDI), which uses national standards to transmit data for reimbursement purposes.,9,Evolution of health care deliver
6、y in the United States,1996 The Health Insurance Portability and Accountability Act (HIPAA) was passed. It mandates administrative simplification regulations that govern privacy, security, and electronic transaction standards for health care information.,10,Evolution of health care delivery in the U
7、nited States,1996 The Healthcare Integrity and Protection Data Bank (HIPDB) was created which combats fraud and abuse in health insurance and health care delivery by alerting users to conduct a comprehensive review of a practitioners, providers, or suppliers past actions.,11,Healthcare Integrity and
8、 Protection Data Bank,Access to information in the HIPDB is available to entities that meet the eligibility requirements defined in Section 1128E of the Social Security Act and the HIPDB regulations. In order to access information, eligible entities must first register with the Data Bank. HIPDB info
9、rmation is not available to the general public. However, information in a form that does not identify any particular entity or practitioner is available.,12,Healthcare Integrity and Protection Data Bank,http:/www.npdb-hipdb.hrsa.gov/ Estimates of annual losses due to health care fraud range from 3 t
10、o 10 percent of all health care expenditures-between $30 billion and $100 billion based on estimated 1997 expenditures of over $1 trillion and 2.5 trillion for 2009.,13,Continuum of Care,A complete range of programs and services is called a continuum of care, with the type of health care indicating
11、the health care services provided. Primary care Secondary care Tertiary care,14,Primary care services,Include preventive and acute care, are referred to as the point of first care, and are provided by a general practitioner or other health professional who has the first contact with a patient seekin
12、g medical treatment, including general dental, ophthalmic 眼科的, and pharmaceutical services.,15,Primary care services,Annual physical examinations Early detection of disease Family planning Health education Immunizations Treatment of minor illnesses and injuries Vision and hearing screening,16,Second
13、ary care services,Provided by medical specialists or hospital staff members to a patient whose primary care was provided by a general practitioner who first diagnosed or treated the patient.,17,Tertiary care services,Provided by specialized hospitals equipped with diagnostic and treatment facilities
14、 not generally available at hospitals other than primary teaching hospital or Level I, II, III or IV trauma centers.,18,Trauma centers,Level I: provides the highest level of comprehensive care for severely injured adult and pediatric patients with complex, multi-system trauma. Level II: broad range
15、of sub-specialists are on-call and promptly available to provide consultation or care.,19,Trauma centers,Level III: physicians are advanced trauma life support (ATLS) trained and experienced in caring for traumatically injured patients; nurses and ancillary staff are in-house and immediately availab
16、le to initiate resuscitative measures.,20,Trauma centers,Level IV: critically injured patients who require specialty care are transferred to a higher level trauma system hospital in accordance with pre-established criteria.,21,Tertiary care,Burn center treatment Cardiothoracic and vascular surgery I
17、npatient care for AIDS patients Magnetic resonance imaging (MRI) Neonatology level III unit services Neurosurgery Organ transplant,22,Tertiary care,Pediatric surgery Positron emissions tomography (PET) Radiation oncology Services provided to a person with a high-risk pregnancy Services provided to a
18、 person with cancer State-designated trauma centers Trauma surgery,23,Positron emissions tomography (PET),builds images by detecting energy given off by decaying radioactive isotopes. Isotopes are atoms of an element with the same number of protons (positively charged particles) in the nucleus, but
19、a different number of neutrons (neutral particles). Because radioactive isotopes are unstable, as they decay, they throw off positrons that collide with electrons and produce gamma rays that shoot off in nearly opposite directions.,24,PET http:/www.doemedicalsciences.org/abt/sidebars/pet.shtml,PET s
20、ystems use the paths of the two detected gamma rays to determine the originating collision point, a process called electronic collimation (瞄準). The scanners use a circular series of gamma ray-detectors to envelope the patient so both gammas can be detected so the instrument can use electronic collim
21、ation to predict where the energy signal originated. This signal is then converted into a three-dimensional image slice.,25,台灣醫院分類,診所 地區醫院 (497/2005) 區域醫院 (80/2005, 65/2006, 64/2007) 醫學中心 (23/2005, 18/2006, 19/2007, 14/2009),26,醫學中心,在衛生局登記開放的急性一般病床與急性精神病床合計須達五百床以上 至少應能提供 家庭醫學、內、外、婦產、兒、骨、神經外、泌尿、耳鼻喉、眼
22、、皮膚、神經、精神、復健、麻醉、放射線、病理、核醫、牙 等十九科之診療服務。,27,醫學中心,專任主治醫師人數 (包括主任在內) 每八床應有一名。專任護理人員每2床至少1名。 加護病房：每床2.5名。 手術室：每班每台2.5名。 手術恢復室：每班每床0.5名。 產房及待產室：每床2名。 嬰兒室：每床0.4名。 急診室：觀察室每床0.5名； 診療室每12人次1名。 門診：每班每診療室0.5名。 血液透析室：每4人次1名。 行政、教學、研究及其他護理人員 (如院內感染控制、公衛、供應中心等護理人員) 另計，應佔總人數百分之六。 應有受過感染控制訓練之專任護理人員，每300床應設1名。,28,醫學中
23、心,藥事人員每40床至少1名。 每60張門診處方至少1名。 特殊藥品處方每15張至少1名。 藥事人員總數至少四分之三為藥師。 藥事人員至少有4名負責藥品管理諮詢及臨床等工作。,29,區域醫院,應設置250床位以上急性病病床數 每床所擁有的樓地板面積應在50平方公尺以上 每9床至少應擁有一名主治醫師 每2.5床至少應擁有一名護理人員等。 至少應能提供 家庭醫學、內、外、婦產、兒、骨、耳鼻喉、眼、精神、復健、麻醉、放射線、病理、牙 等十四科之診療服務。,30,區域醫院 Nurse,加護病房：每床2名。 手術室：每班每台2名。 手術恢復室：每班每床0.5名。 產房及待產室：每床1.2名。 嬰兒室：每
24、床0.4名。 急診室：觀察室每床0.5名； 診療室每12人次1名。 門診：每班每診療室0.5名。 血液透析室：每4人次1名。 行政、教學、研究及其他護理人員 (如院內感染控制、公衛、供應中心等護理人員) 另計，應佔總人數百分之四。 應有受過感染控制訓練之專任護理人員，每300床應設1名。,31,區域醫院,藥事人員每50床至少1名。 每70張門診處方至少1名。 特殊藥品處方每15張至少1名。 藥事人員總數至少四分之三為藥師。 藥事人員中，至少有2名負責藥品管理諮詢及臨床等工作。,32,地區醫院,在衛生局登記開放的急性一般病床需20床以上， 急性一般病床及急性精神病床合計249床（含）以下。,33
25、,地區醫院,專任員工總人數每床應有1名。 專任主治醫師人數以及專任護理人員應符合醫療機構設置標準。 藥事人員每50床至少1名。 每80張門診處方至少1名。 每增加100張處方應增加1名。 應有藥師1人以上。,34,評鑑分級,設施 總樓地板面積 病房設施 安全設備及一般設備 保險病床比率,35,評鑑分級,人員 員工總人數 醫師總數 麻醉科醫師 放射線科醫師 核醫科醫師 病理科醫師 復健科醫師 精神科醫師 護理 藥事 醫事檢驗 醫用放射線技術 復健技術 精神科 社會工作 營養師 病歷管理,36,評鑑分級,醫療業務及設備 醫療業務 急性病床數 診療科別 急診業務 手術及麻醉作業 產房 嬰兒室 加護病
26、房 藥事作業 檢驗作業 輸血作業 放射線診療作業 病理作業 復健醫療作業 精神科 核子醫學 牙科 特殊醫療服務 醫務社會服務工作 營養部門 病歷部門 社區衛生服務 員工健康檢查,37,評鑑分級,品質保證 醫療品質審查 感染控制 人體試驗 藥事作業品質 護理服務品質 檢驗作業品質管制 輸血作業品質管制 病理作業品質管制 放射線診療品質管制 核子醫學品質管制 病歷管理 醫院管理業務 醫病關係之促進,38,評鑑分級,指定項目評估 住院 診斷 處置 用藥 手術 病歷寫作,39,評鑑分級,教學訓練 教學師資 教學訓練與研究設備 教學訓練活動 與其他醫院(醫學院)交流合作情形 研究情形及論文發表 教學進修
27、研究經費,40,新制教學醫院評鑑基準,教學資源 教學訓練計畫與成果 研究執行與成果 臨床師資培育及繼續教育 學術交流與社區功能及角色 管理行政,41,財團法人醫院評鑑暨醫療品質策進會,http:/www.tjcha.org.tw/Identify.asp?catid=23,42,Health Care Facility Ownership,Government (not-for-profit) 25% Proprietary (for-profit) 15% Voluntary (not-for-profit) 60%,43,Medical Staff,Intern: a physician
28、in the first year of graduate medical education, which ordinarily immediately follows completion of the four-year medical curriculum. Resident: a physician who has completed an internship and is engaged in a program of training designed to increase his or her knowledge of the clinical disciplines of
29、 medicine, surgery, or any of the other special fields that provide advanced training in preparation for the practice of a specialty.,44,Medical Staff,Chief resident: a physician who is in his final year of residency or in the year after the residency has been completed. Visiting Staff (VS): 主治醫師,45
30、,Health Care Facility Organizational Structure,Governing board Administration Medical staff Departments, services, and committees Contracted services,46,Governing board,The governing board (board of trustees, board of governors, board of directors) serves without pay, and its membership is represent
31、ed by professionals from the business community.,47,Administration,Serves as liaison between the medical staff and governing board and is responsible for developing a strategic plan for supporting the mission and goals of the organization. CEO: chief executive office CFO: chief financial officer CIO
32、: chief information officer COO: chief operating officer,48,Medical staff,Consists of licensed physicians and other licensed providers as permitted by law (e.g., nurse practitioners and physician assistants) who are granted clinical privileges.,49,physician assistants,Examine, diagnose, and treat pa
33、tients under the direct supervision of a physician.,50,Medical staff membership categories,Active: delivers most hospital medical services, performs significant organizational and administrative medical staff duties Associate: advancement to active category is being considered Consulting Courtesy: a
34、dmits an occasional patient to the hospital Honorary,51,52,Hospital departments, Services, and Committees,53,NTUH Departments,秘書室 總務室 企劃管理室 病歷資訊管理室 醫療事務室 社會工作室 公共事務室 工務室 資訊室 圖書室 安全衛生室 警衛隊 會計室 人事室 教學部 醫學工程部,54,NTUH Departments,內科部 外科部 骨科部 婦產部 小兒部 神經部 精神部 耳鼻喉部 眼科部 泌尿部 皮膚部 牙科部 復健部 家庭醫學部 麻醉部 影像醫學部 核子醫學部
35、 檢驗醫學部 病理部 藥劑部 護理部 營養部 綜合診療部 醫學研究部 基因醫學部 門診部 急診醫學部 腫瘤醫學部 創傷醫學部 老年醫學部 環境及職業醫學部,55,NTUH Departments,品質管理中心 資財管理中心 健康管理中心 肝炎研究中心 形體美容醫學研究中心 國家級卓越臨床驗與研究中心,56,抗老及健康諮詢中心 心臟衰竭中心 乳房醫學中心 感染控制中心 運動醫學中心 過敏免疫中心 臨床心理中心 健康教育中心 睡眠中心 國際醫療中心,57,The Johns Hopkins Hospital,Allergy and Clinical Immunology Anesthesiolog
36、y/Critical Care Medicine Cardiology Dermatology (Skin) Emergency Medicine Endocrinology 內分泌學 Gastroenterology 胃腸病學 Gynecology & Obstetrics 婦產 Hematology 血液學 Infectious Diseases Internal Medicine Nephrology 腎病學 Neurology & Neurosurgery,58,The Johns Hopkins Hospital,Oncology (Cancer) Ophthamology (Eye
37、s) Orthopedic Surgery 整形外科 Otolaryngology (ENT) Pediatrics 兒科 Physical Medicine/Rehabilitation Psychiatry/Behavioral Sciences Pulmonary/Critical Care Medicine 肺 Radiology Surgery Urology 泌尿科,59,Internal Medicine,Adolescent medicine Cardiovascular medicine 心血管 Critical care medicine Electrophysiology
38、 電生理學 Endocrinology 內分泌學 Gastroenterology 胃腸病學 Geriatrics 老年醫學 Hematology 血液學 Immunology Infectious disease Nephrology 腎病學 Oncology Pulmonary medicine 肺 Rheumatology 風濕病學 Sports medicine,60,Hospital Departments,Admitting (Patient Registration) Biomedical Engineering Business Office Case Management (
39、Discharge Planning) Central Sterilizing Service Chaplain Clinical Laboratory Community Relations (Public Relations),61,Hospital Departments,Compliance Computing Durable Medical Equipment Electroneurodiagnostic Testing Emergency Room Employee Assistance Program (EAP) Employee Health Services Environm
40、ental Services Health Information Management Services,62,Hospital Departments,Hospice Care Human Resources Medical Education Medical Library Medical Staff Nursing Nutrition and Food Service Occupational Therapy,63,Hospital Departments,Operating Room Suite Patient Advocacy Patient Education Performan
41、ce Improvement Pharmacy Physical Therapy Plant Operations and Maintenance Preadmission Testing (PAT),64,Hospital Departments,Purchasing Radiation Oncology Radiology Recreation Therapy Rehabilitative Services Respiratory Therapy Respite Care Risk Management Safety Management,65,Hospital Departments,S
42、ocial Services Speech and Language Pathology Telemedicine Utilization Management Volunteer,66,Hospital Committees,Disaster Control Drug Utilization Review Education Finance Forms Health Information Infection Control Quality Management Risk Management Tissue Review Transfusion Utilization Management,
43、2009/11/19,67,68,Health Information Department,Department administration Cancer registry Coding and abstracting Image processing Incomplete record processing Medical transcription Record circulation Release of information processing,69,70,Coding,Involves assigning numeric and alphanumeric codes to d
44、iagnoses, procedures, and services; this function is usually performed by credentialed individuals. Coders assign ICD-9-CM codes to inpatient cases and Current Procedural Terminology (CPT), Health Care Procedure Coding System (HCPCS) Level II (National), and ICD-9-CM codes to outpatient, emergency d
45、epartment, and physician office cases.,71,Cancer registry,Performed by individuals who are credentialed as certified tumor registrars and include using computerized registry software to conduct lifetime follow-up on each cancer patient, electronically transmit data to state and national agencies for
46、 use at local, regional, state, and national levels, and generate reports and information for requesting entities.,72,Current Procedural Terminology (CPT),Published annually by the American Medical Association and codes are 5-digit numbers assigned to ambulatory procedures and services. E.g. 90663 I
47、nfluenza virus vaccine, pandemic formulation,73,ICD-9-CM,The International Classification of Diseases, Ninth revision, Clinical Modification is used in the United States to collect information about diseases and injuries and to classify diagnoses and procedures. National Center for Health Statistics
48、 (NCHS).,74,http:/ INFECTIOUS AND PARASITIC DISEASES (001-139) TUBERCULOSIS (010-018) Includes: infection by Mycobacterium 分枝桿菌 tuberculosis (human) (bovine 牛) Excludes: congenital tuberculosis (771.2) late effects of tuberculosis (137.0-137.4) The following fifth-digit subclassification is for use
49、with categories 010-018: 0 unspecified 1 bacteriological or histological 組織學的 examination not done 2 bacteriological or histological examination unknown (at present) 3 tubercle bacilli 結核桿菌 found (in sputum) by microscopy 4 tubercle bacilli not found (in sputum) by microscopy, but found by bacterial culture 5 tubercle bacilli not found by bacteriological examination, but tuberculosis confirmed histologically 6 tubercle bacilli not found by bacteriological or histological examination, but tuberculosis confirmed by other methods inoculation 預防接種 of animals,
