Geneva Health Forum Archive

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Making Public Hospitals Ready for the Future: SDC Experience with Reforming Perinatal Care in Romania

Author(s): M. Zahorka*1, N. Fota2
Affiliation(s): 1Swiss Centre for International Health, Basel, Switzerland, 2CRED-Centre for Health Sector Development, Bucharest, Romania
Keywords: Capacity building, guidelines, quality management, patient-oriented care, mortality impact
Background:

The Swiss Agency for Development and Cooperation (SDC) supported the Romanian Ministry of Health it its efforts to modernise its perinatal services through the RoNeonat project from 2002 to 2007. Started as a pilot in two health regions in 2002, the project up-scaled its experience to a nationwide level within the World Bank supported National Health Sector Reform Programme.

Summary/Objectives:

The project objective was to ‘modernise the Romanian neonatology system’ based on a regional health systems approach. After an initial infrastructure improvement (technical equipment, rehabilitation of buildings) and a continuous training programme, the project complemented the services offered (post NICU follow up, neonatal transport services) and developed a comprehensive management approach based on a Quality Management framework. Elements supported were EBM based Clinical Practice Guidelines, management of modern health technology, hospital budget reform, the introduction of Quality Management principles with a client centred approach and improvement of referral system.

Results:

Central criteria for a modern healthcare system are its effectiveness and efficiency, the comprehensiveness, response to client needs, improved health outcomes and less adverse outcomes. Some results are: The number of in utero and neonatal transfers to level III maternities increased by more than 20%, between 2005 and 2007, which indicates an improved functioning of the regional referral systems. A new preference for in-utero transfer versus neonatal transfer is indicated through the number of women registered for birth at a reference level maternity, who are not from the same district. This figure increased by up to 30% between 2005 and 2007 in some project regions. Services statistics show that the utilisation of neonatal hospital beds generally increased to a level above 220 days/bed and year. Referral centres generally expected an increase in the utilisation rates of 10% between 2006 and 2007 to more than 82%. At the same time the average hospitalisation length in these centres decreased by 16%, which indicates an increase in efficiency of services. Participating hospitals chose a more client oriented approach and based many of the small improvements on the results of client satisfaction surveys, management reviews and interdisciplinary quality circles. Two out of seven participation regional neonatology wards successfully underwent a certification process according to ISO 9001:2000.
Although the mortality and morbidity impact of the improvements is statistically difficult to prove, there is indication of such changes: (1) The infant mortality in the Iasi region decreased between 2003 and 2006 by more than 28% compared to a decrease 19% at the national average. (2) Neonatal mortality decreased in the same region by 30% (to 4.2‰) versus a national average decrease of 11% (to 7.8‰).

Lessons learned:

Modernising health institutions needs a comprehensive approach imbedding technology upgrades and continuous capacity building into an overall quality framework including structural, procedural and outcome quality. Professional communication, the introduction of IT technology, the participation in benchmarking systems can support continuous improvement processes through a best practices approach. Although many East European health institutions and systems have internal quality assurance systems in place, access to international networks is an added advantage and European professional associations have more to do to incorporate Eastern European partners.

Leveraging Tele-Health for Strengthening Health Systems and Workforce: Transition from Project Mode to a Sustainable Model with Public-Private Partnership

Author(s): P. P. Venugopalan1, M. K. Nabeel*2
Affiliation(s): 1Dean, 2Medical College, Kannur, Kerala, India
Keywords:

Tele-health, tele-medicine, informatics, technology in healthcare, health system reform, public private partnership

Background:

The Kerala Tele-health & Medical Education (TH&ME) project was initiated three years ago by the State Government with support from the Indian Space Research Organization (ISRO). An IP based system, working on satellite technology, it has got its own merits and a few demerits as well. Even prior to this project there were small initiatives within the country making use of similar technology, but this was a major leap in the roll out after identifying the potential benefits of a state-wide network.

Summary/Objectives:

Setting apart the spurts of activities in the initial days and the consistent activities from very few centres, it is found that the installations at most centres in the project are grossly underutilized. The factors affecting the adoption of this technology and its utilization were analysed and classified into technology related and non-technology related. Best Practices and value additions at some centres, which enhanced the effectiveness of the project are also documented in the full paper.

Results:

Setting apart the spurts of activities in the initial days and the consistent activities from very few centres, it is found that the installations at most centres in the project are grossly underutilized. The factors affecting the adoption of this technology and its utilization were analysed and classified into technology related and non-technology related. Best Practices and value additions at some centres, which enhanced the effectiveness of the project are also documented in the full paper.

Lessons learned:

We have identified that there are barriers to the adoption of such technologies, even though these technologies itself are brought in to overcome barriers in access to health. Contrary to popular belief, barriers not directly related to technology per-se are more important than those barriers related to technology. Another important lesson learned from this project is regarding the essentiality of a proper needs assessment and prioritization before the launch of any project. Based on the findings of this analysis, this paper further discuss about a proposed public private partnership initiative which tries to integrate public health in general and primary healthcare in particular to this already piloted project. Apart from Tele-Education & Tele-Consultations, plans have been put forward for using the network for sharing other electronic resources and also to use it for enhancing and improvising disease surveillance, health system management and epidemiological research.

Strengthening Health Systems to Support PHC: Experience of Support Project in UWR of Ghana

Author(s): F. K. Nyonator*1, E. K. Sory2, A. Nang-Beifubah1, P. Balagumytime1
Affiliation(s): 1Policy Planning Monitoring and Evaluation Division, 2Director General, Ghana Health Service, Accra, Ghana
Keywords: Health system; facilitative supervision; community action plan
Background:

This is four-year programme Japan International Cooperation Agency (JICA)/Ghana Health Service (GHS) programme aims at improving basic health services in Upper West Region in Ghana under the concept of ‘Human Security and Capacity Development’. The programme started with a technical cooperation project in 2006 focusing on two districts and later expanding to all eight districts in the region by supporting the expansion of functional CHPS zones through strengthening the institutional capacity of GHS on CHPS implementation.

Methods:

The design of the project is to improve the health status of people in Upper West Region through the improvement of access to quality basic health services in rural areas and the mobilization of community members for health promotion activities. Project is evaluated by assessment of the functioning of the District Health Systems and number CHPS zones rolled out.

Results/Conclusions:

This is a project in which resident health care providers brings basic health services to the doorsteps of the people in the impoverished region of the Upper West Region aims to eliminate disparities in access to health services, and improve on its low health indices. This project is enhancing Ghana Health Service’s capability to implement the Community-based Health Planning and Services (CHPS) strategy to serve as a vehicle that takes primary health services to the people in the Upper West Region. Specifically, a facilitative supervision system is being introduced for CHPS activities and improving relevant knowledge and skills among resident community health officers. A referral system from CHPS to health center and hospitals is also established supported by four ambulances and radio communication networks. Furthermore, community people are able to meet and develop Community Health Action Plans and also participate in the project and document best practices with an aim to disseminate within all regions of Ghana.
Having commenced in March 2006, the project had provided 20 separate training courses for CHOs in the Region till August 2009. With those efforts, 140 CHOs are actively working so far and the regional health administration now has the capacity to train CHOs on their own. The local communities work on “Community Health Activity Plans (CHAP)” and raise health awareness, for example, they establish a fund for supporting CHOs, community emergency transportation system (CETS) and others. The Health Improvement Program for the people of the Upper West Region is a strategic one having links to grant aid and Japan Overseas Cooperation Volunteer projects to bring about a synergetic effect between equipment, skills and grassroots support activities to attain the better access to the basic health services.

Taking Stock of an Ambitious Tele-Health and Medical Education Project

Author(s): M. Nabeel1
Affiliation(s): 1Solution Exchange AIDS Community, Knowledge Management Partnership Project, New Delhi, India
Keywords: Tele-medicine, Tele-health, Tele-education, Kerala, India.
Background:

The Kerala Tele-health & Medical Education (TH&ME) project was initiated five years ago by the State Government with support from the Indian Space Research Organization (ISRO). The present paper is taking stock of how the project is performing currently and tries to analyse the factors affecting it.

Methods:

The project is working on an Internet Protocol based system, utilising satellite technology. It has got its own merits and a few demerits as well. Through papers presented previously at this forum, the issues faced by this author as a nodal officer in implementing this project statewide were discussed. A detailed account of the project from its planning stage to the implementation stage was narrated, while the author was working with this project.

Results/Conclusions:

This paper specifically analyses the utilisation of the technology in various teaching and non-teaching hospitals. Setting apart the spurts of activities in the initial days and the consistent activities from very few centres, it is found that the installations at most centres in the project were grossly underutilized. The factors affecting the adoption of this technology and its utilization were analyzed and classified into technology related and non-technology related. Best Practices and value additions at some centres, which enhanced the effectiveness of the project are also documented in the full paper. There are barriers to the adoption of such technologies, even though these very technologies are bought in to overcome barriers in access to health. Contrary to popular belief, barriers not directly related to technology per se are more important than those barriers related to technology. Based on the findings of this analysis, this paper further discuss about a proposed public private partnership initiative which tries to integrate public health in general and primary health care in particular to this already piloted project. This paper also suggests a logical next step in taking this project forward which holds tremendous potential.

Egypt National Authority for Quality Assurance and Accreditation Guidelines versus Regional Guidelines of (EMRO) for Accreditation of Medical Schools

Author(s): S. A. E. ElMeneza1
Affiliation(s): 1Pediatrics, Faculty of Medicine for Girls, ALAzhar University, Cairo, Egypt
Keywords: NAQAAE, EMRO, Accreditation, Medical school, Doctors 2040
Background:

Accreditation of Medical Schools is essential requirement not only to indicate quality of learning but also for social accountability and trust. Accreditation is the means for providing standards that guide the process of development and reform of medical education. By adopting such standards, medical schools are expected to achieve quality assurance measures and meet the demands of the beneficiaries (students, community …etc.) in addition to stakeholders. Majority of medical schools in developing counteries are not yet accredit and face challenges to get trust on national and international levels. To compare between WHO regional office accreditation guidelines for medical schools and National Authority for Quality Assurance and Accreditation (NAQAAE) of Egypt guidelines and to determine if these guidelines are suitable to prepare physicians for their roles in year 2040.

Methods:

Midline search of data base including accreditation of medical schools ,WHO guidelines and global standards developed by WFME as well as NAQAAE and Faculty of Medicine for girls self study 2005-2006.

Results/Conclusions:

Search showed that WHO regional office had assigned a group of experts to prepare regional guidelines to help establish an accreditation system for health professions education in countries of the region based on national sets of standards. Faculty of Medicine for Girls, ALAzhar University, and Cairo, Egypt had adopted these guidelines in its self study published 2005-2006. In 2007, National authority for quality assurance and accreditation (NAQAAE) developed. NAQAAE introduced directory of accreditation for Egyptian higher education institutions in July 2008. The directory is composed of 2 components: first component: descriptive data for the organization, second component: process of self study according to NAQAAE regulations and standards which include 2 axes each have 8 standards, each standard has indicators, each indicator has elements and each element has its criteria. In our institution; Faculty of Medicine for girls, ALAzhar University we have to move from adopting the WHO standards to NAQAAE regulations and standards in order to submit for national accreditation. We found that there are points of similarity and points of difference between regional standards (EMRO) and the Egyptian national accreditation standards (NAQAAE). Similarities were found in purpose and rational, but there are several differences in the domains, standards & indicators for each standard. For example in EMRO there are, 11 domains, 3 levels of standards & indicators for each standard, as well as 3 levels of standards for each domain, sub-standard (level 0), basic standard (level 1) and essential standard (level 2). While in NAQAAE, there are 2 main axes: one for institutional capability and the other for educational effectiveness, each includes 8 standards and indicators for each standard, elements for each indicator and criteria for each element. Standards represent the area (domain) to be judged and not the level of judgement. Evaluation of standards is done from collective evaluation of criteria (rubrics is done for evaluation). Also there is differences in the process of accreditation. Others similarities and differences will be discussed.
Earlier adoption of EMRO guidelines in our institution helped for awareness and motivation of the staff, forming committee to improve quality, engagment of the students in process of quality. In comparison to regional and global standards of NAQAAE, it gives more elaborative description with stress on every procedure in the organization and gives details of best practices in institutions of higher education. Still questions need to be answered regarding globalization of training of medical students in order to ensure globalisation of healthcare and to prepare medical students world wide for qualifications of 2040 physcians.

Hopes: Lessons from a Practical Example

Author(s): Line Kleinebreil1
Affiliation(s): 1Direction informatique, Hôpital européen Georges Pompidou, Paris, France
Key issues: How to increase access to medical information is an important issue. In most developing countries there is no postgraduate training organisation able to react to emerging diseases or severe epidemic. The digital world creates new opportunities.
Meeting challenges: Partnership between medical experts (public health, epidemiologists, internists) and IT experts is necessary to design, implement and evaluate programmes in the field. The design of HOPES (health operational programme through education and sentinel network) has addressed the following questions with following answers: (1) Final target? Reduce morbidity and mortality, especially child mortality. (2) Health care professionals to be reached by the programme? Primary care professionals, physicians, nurses, and midwives. (3) Topics? They have to be discussed with the countries. Since 2005, HOPES has developed 3 modules of 60 hours each addressing immunization, prevention of HIV transmission, and best practices for most frequent clinical situations. (4) Motivation? Partnership with local university and health ministry is crucial to organize the training and its recognition in the health system. (5) Technical solution? The most important issue is to have a stepwise approach, from DV/CD player, basic mobile phone, up to satellite videoconference. Flexibility is necessary to use existing infrastructure, overcome technical barriers and provide information where needed. (6) Resources? At least 50% of necessary human resources have to come from the developing country in order to disseminate valid medical information in the local context. Infrastructure budget should also be partially supported by the country, even if international agencies help in the initial phase. (7) Sustainability? Partnership is a key issue. North/south, medical and IT partnerships, but also outside the medical world. Extending the local use of communication channels for dissemination of information related to complementary areas is necessary to cover long-term financial costs.
Conclusion (max 400 words): After 18 months of deployment, the HOPES programme has provided medical information to primary health care professionals in Mali and Burkina Faso. Partnership with the RAFT programme is set up to extend geographical access to medical information and share scare pedagogical resources.

Putting Research Evidence into Practice

Author(s): Nirmal Kumar Ganguly1
Affiliation(s): 1Director General, Indian Council of Medical Research, New Delhi, India
Key issues: Impressive strides have been made in biomedicine and it is on account of the results of health research that the people enjoy a longer life expectancy through use of products of research like the vaccines, drugs, diagnostics, better management of diseases and life threatening conditions. However, benefits of health research are not available to those countries, communities and individuals that need it most.
Meeting challenges: In India, the burden of ill-health is higher among the poor. The infant mortality rate is two and half times higher and the under-five mortality rate is three times higher in the lowest quintile of the population as compared to the highest. The total fertility rate in the highest quintile is almost half that of the lowest quintile of the population. Although the burden of disease is high among the poorest quintile, their access to health services is limited. The poorest 20% of the population get only 10% of the public subsidies for curative care. There is an urgent need, therefore, to identify approaches and means to translate knowledge to effective interventions to improve access to health care and services. This means better utilization of existing tools, development of new tools for diagnosis, treatment and prevention of diseases as well as working out strategies that would result in their reaching the population in greatest need.
Conclusion (max 400 words): The research activities of the Indian Council of Medical Research (ICMR), the apex body for biomedical research in the country are aimed at reduction of poverty through income-generating schemes, catalysing community participation in disease control programmes, developing innovative strategies that generate income, decreasing the man-days lost due to illness and loss of wages by developing more effective treatment and of shorter duration. Studies aimed at promoting gender equality and empowering women for contraceptive choices have led to the development and introduction of newer contraceptives including emergency contraception and safe abortion methods in the country. To improve child survival, studies on home-based newborn care interventions, estimating the disease burden for vaccine-preventable diseases and evaluating alternative modes of delivery of existing vaccines have led to some effective management strategies. Studies for improving maternal health have led to the development of feasible and cost-effective methods and management strategies to prevent and treat maternal morbidities. Research in nutrition has led to the formulation and implementation of national nutrition programmes, use of iodized salt and availability of fortified foods in the country. Development of diagnostic kits and effective treatment regimens for infections such as HIV/AIDS, malaria, TB and others diseases like Leishmaniasis have been given additional emphasis. Studies to understand the disease burden, epidemiology, risk factors and also genetic disorders like heamoglobinopathies have provided inputs for development and implementation of national health programmes and integrated disease surveillance in the country. Research in diabetes has facilitated preventive measures and improved management strategies. Mapping of diseases like cancer has helped in formulating strategies for prevention and management. For ensuring environmental sustainability, studies on impact of air pollution, occupational exposures, monitoring pesticides in environment and food and developing bio-markers for detection of environmental toxins have been carried out. Pre-clinical and clinical testing of newer molecules developed by Indian pharmaceutical companies has led to production of newer drugs for disease management. The clinical trial registry at ICMR will further help in evidence-based interventions and implementation of best practices in the country.

GHF2006 – PL04 – A Critical View on the Role of Hospitals in Increasing Access to Health

Session outline

Plenary session, PL04, Thursday, August 31 2006, 18:00-19:30
Chair(s): Peter Saladin, Switzerland, Elisabeth Leforestier, France
Hospitals Promoting Access to Healthcare
Gillian Morgan, The NHS Confederation, London, United Kingdom 
Adeleke Olusegun Pitan, Honourable Commissioner for Education, Lagos State Ministry of Education, Lagos, Nigeria 
Redesigning Hospital Care to Meet the Needs of the Community
Wim Schellekens, Centre for Innovation and Development, Dutch Inspectorate, Leiderdorp, The Netherlands
Optimizing Hospitals in the Health Sector
Saleh Meky, Minister of Health, Eritrea 

Session Document

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Session report

Submitted by: Irene Amodei (ICVolunteers); Contributors: Melissa Bonnefin (ICVolunteers)

"Brain drain in health systems is a political issue". Image: Viola Krebs, ICVolunteers.org

Hospitals have always played a pivotal role in the global healthcare system. They have power, authority and professional competences in both the rich and poor worlds. But what if we all begin to re-think the mission of hospital care and re-design the way we deliver it in order to increase access to health? The moment has arrived for reform in order to achieve optimal care, to learn from examples of real innovation and disseminate this knowledge, sharing ideas as well as best practices.

Mr. Adeleke Pitan, Honourable Commissioner for Education in Lagos' State Ministry of health from 1999 to 2006, began the plenary session with a detailed overview of the state of the health care delivery system in Nigeria and urban Africa. "Access to health has always been, and still remains, a problem in many urban areas" stated the former Minister, "due to uneven distribution of hospitals, inadequate health personnel, limited financial resources and weak motivation of the workforce". He then narrowed his focus criticizing the current inadequate knowledge and health education of the population (estimated at 150 million people) who still prefer alternative medicine practitioners. About 75% of Nigerian government hospitals are in urban areas and 25% in rural ones and on average 2.2 million patients are treated each year. The need to increase access to health has pushed the government to develop 'packages' to attract the elderly and most vulnerable groups; to introduce a number of free health services including free anti-natal care, free medical treatment for children aged between 0 and 12 years and for people over the age of 60. The Health Sector Reform programme also included free heart surgery for patients with heart defects, free eye treatment including surgery for cataracts and glaucoma and free breast cancer screening. Mr. Pitan described the opportunities that the reform offered such as Public-Private Partnership initiatives (PPP's),  the B-O-T system (build, operate and transfer), transfer of technology, training and re-training of health personnel. While the reform process has helped to assist the most vulnerable part of the population, trying to bring health to the doorstep of all citizens continues to be a major problem due to the small number of hospitals, shortage of specialist manpower, the lack of equipment and under-funding of the health care system.

'Reform' was also the key word of the presentation by the Minister of Health in Eritrea, Mr. Saleh Meky, who explained in detail the series of strategies adopted nationally in order to increase the cost-effectiveness of the health system and of its delivery services. "Change means new ways of thinking and acting", stated Mr. Meky, "and must be managed to ensure the result is a real improvement. Moreover, the quality of clinical services must not suffer during periods of rapid change". As a result of the concerted efforts made in Eritrea to build new health facilities and give them the necessary equipment and skilled health personnel, access to primary health care within 10 km from the health structures increased in the last years to around 70%. A good deal, given that 50% of the population lives within an area of 5 km.

Mr. Meky illustrated the main goals of the national reform, namely:

  • To ensure the equitable distribution of health services to rural and urban areas;
  • To strengthen Primary Health Care especially in remote and inaccessible areas;
  • Actively to promote the dissemination of accurate information on health practices;
  • To use a strong evidence-based decision-making process.

According to Mr. Meky, the basic principles of any health system reform are the improvement of management (namely the Health Management Information System, HR management, quality and financial management) and the decentralization of functions "to that level where optimum value can be attained". A country in transformation, like Eritrea, has to deal with additional challenges, for example the urgent need to control both tropical (historical) and 'rich-countries' (new to Eritrea) diseases. For that reason, the decentralization process is often not easily manageable. As a solution Mr. Meky introduced the concept of "hospital autonomy", an alternative method of organizing and financing health care services. Hospital autonomy could also be seen as an effective merge of the best elements of the public and private sectors; a kind of parastatal hospital that works in a private way from the point of view of finance and bureaucratic reduction, which when properly implemented, enhances effectiveness and efficiency.

Mr. Meky ended his presentation by stressing the need for stronger community involvement as the only way to overcome the always present danger of brain drain. "Brain drain in health systems is a political issue" stated the Minister. "If we want to have some chance to stop it we must provide a comfortable ecological and financial environment, to train as many people as possible, to appeal to people's nationalism and, most importantly, to make people think that they really are the owners of their hospitals".

Mr. Wim Schellekens, CEO of the Center for Innovation and Development in The Netherlands, offered the plenary a mostly self-critical 'first-world' point of view. "How effective and safe is hospital care?" questioned Mr. Schellekens, "How to do a better job?".

Despite the progress of medical science, we still see a huge amount of errors in the way we deliver care (overuse, under use or misuse of drugs), in the way we organize care (coordination problems and delays) and in the way we take care (absence of transparency, empathy and patient-involvement). In the USA, there are 44,000 to 98,000 deaths in hospitals each year (8th-3rd cause of death) and there is no correlation between cost and mortality. Care for patients should be safe, effective, patient-centred, timely and efficient, with equity for all. Patients, of course, do not expect needless deaths, needless pain, unwanted waits and helplessness. In short, quality is the big issue. To support his claims Mr. Schellekens described the successful IHI Boston experience in 2004, which, with six simple interventions (like the creation of a Rapid Response Team), resulted in 122,300 lives saved in the 3,000 hospitals involved. The key to success is to have vision, a strategy and leadership ("First study, then act; first plan then do!"). The theory affirms that when we have convinced 20% of our target, the rest will automatically follow. In The Netherlands the "Better Faster" programme, that aimed to get breakthrough results in 20 % of Dutch hospitals in four years, succeeded by acting at four levels of intervention: system level, institutional level, level of care-process and patient level. According to Mr. Schellekens the mission of hospitals has shifted from "delivering specialized care to our patients" to "responsibility for the care in our region" to "promote health to all our citizens".

Redesigning Hospital Care to Meet the Needs of the Community

Author(s): Wim Schellekens1
Affiliation(s): 1Centre for Innovation and Development, Dutch Inspectorate, Leiderdorp, The Netherlands
Key issues: Hospitals are an essential part of our healthcare system. In hospitals we see the progress of medical science. But how content can we be with the current status of our hospitals? What are the main issues in hospital care in most developed countries? Wherever we measure, we see a huge variation in the way care is offered and organised. We harm patients by the way we deliver and organize care which results in unnecessary suffering and even death. We have compartmentalized our care between disciplines, departments and institutions. Our care is too much doctor/organisation-centred instead of patient-centred. There is a wall between public health and our cure-system. Hospital care takes almost all our healthcare money, but what is the costeffectiveness ratio? In many places we see remarkable improvements and examples of real innovations of care. But what about implementation of this knowledge and dissemination of these best practices? What we need is interventions on four different levels: 1) Patient level: patients can be the main driving force for innovation and improvement; 2) Process level: here we need the innovation and improvement; 3) Organisational level: leadership, organisational support, redesign of the support processes, HRM and IT; 4) Level of the health care system: how about the financial incentives, the healthcare insurance system, the legal issues, etc.? Let me focus on some fundamental issues for innovation and change: 1. Leadership: I have seen a shift in the mission of hospitals: from delivering specialised care to patients, to responsibility for the healthcare in our region, to responsible to improve health in our region. Leaders are responsible for the level of ambition. They translate mission and vision into strategy and operational goals, and they are able to develop and apply a strategy for implementation and spread. They make the link between quality and finance. 2. A strategy to improve quality and safety: We need a quality-system, multidisciplinary cross-functional and cross-organisational collaboration, a framework of methods and tools, training, and a strategy for implementation and spread. 3. Involvement of patients: We have not so much experience in involvement of patients in our daily care-delivery or our improvement efforts. This will bring us to a new level of performance. 4. Specialisation and stratification of care: Quality results depend on the experience of the care team. It becomes a necessity to concentrate high-tech care and the care for rare diseases in centres of excellence and to focus on high quality standardized care for the common diseases and low/medium-tech care in our regular hospitals: a vertical integrated system. At the same time it shows that we can get much better results if we stratify our care in acute, elective and chronic care. 5. Outreach to public health: The knowledge and experience of hospital workers should be applied in public health primary prevention, immunisation programs, screening for early detection of diseases, self-help of patients and patient-groups, public information, etc. There still is a big gap between health care and social care, education, welfare, living, etc.
Conclusion (max 400 words): Rethinking the mission of hospital care and redesigning the way we deliver hospital care is urgent. It is the task of leaders in this field to take up the challenge.

Closing the Gap: Migrant-Friendly Health Systems in America

Author(s): Patricia F. Walker1
Affiliation(s): 1Department of Internal Medicine, University of Minnesota, St Paul, USA
Key issues: Complex interactions between the patient, the health care delivery system and providers all impact satisfaction and outcomes for immigrants to America. 99.3% of Americans are first-generation immigrants or children of immigrants, and yet the struggle of the immigrant to receive high quality care in America has yet to be resolved. This presentation will provide an overview of demographic changes in America, and key barriers to care for immigrants. Highlights of key national and statewide initiatives to provide high quality, effective care for immigrants will be described. What does a migrant-friendly hospital or health system consist of in the US specific examples from Minnesota, the state which receives more refugees as a percentage of immigration than any other state in the USA, will be detailed.
Meeting challenges: Well documented disparities in health care and disease outcomes exist for immigrants, even after correcting for access to care, which in and of itself is a fundamental barrier to care in the USA. Issues of language and culture are key determinants of use of health services. Utilization is also impacted by gender, age, race and ethnicity, as well as experiences within the health care delivery system in an immigrant’s country of origin. Prevalence rates for chronic diseases vary by race/ethnicity, country of origin and time since immigration, and make it challenging for clinicians to have an adequate set of skills and knowledge to care for patients from many different countries, ethnic and cultural backgrounds. Medical schools and graduate training programs struggle with implementing educational models adequate to train the next generation of physicians in global health. Clinician attitudes and behaviors, skills and knowledge base also play a role in contributing to health disparities for immigrants. The tragedy of global inequity persists in the developed world.
Conclusion (max 400 words): Providing a common framework for addressing immigrant disparities issues is critical to programmatic success. That framework must be the language of quality. Using the Institute of Medicine’s Quality Chasm and Unequal Treatment Reports, the author will describe groundbreaking work on demographic data collection, and quality measures for minority communities. Specific examples will include: 1) the work of a large integrated care delivery system, HealthPartners, in reducing disparities; 2) implementation of a 3-year program in best practices in care for hospitalized patients with limited English proficiency, in a large urban hospital; 3) description of a nationally recognized Center for International Health; 4) recommendations from a best practices expert panel report on refugee and immigrant health; and 5) development of an academic Global Health Pathway at the University of Minnesota. Participants will receive resource materials, and hear live stories from the front lines of the US experience with refugee and immigrant health care.