Hospitals in Health Systems: Opportunities for Efficient, High-quality, and Integrated Care

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Table of Contents

• Contents 3
• Tables 4
• Figures 5
• Acknowledgments 7
• About the Authors 8
• Authors 8
• Abbreviations and Acronyms 13
• Executive Summary 16
• Hospitals and Health Care 16
• Three Key Operating Principles 17
• Areas of Action 17
• Future Opportunities 18
• Figure 1: Insights Across Four Key Areas of Reform (Chapter Topics) 18
• References 18
• SECTION 1 Overview 19
• Chapter 1: Overview: Why Hospitals, and Why This Publication 20
• Hospitals and Health Care 20
• Hospitals and Primary Care: Complementary Components for Health 20
• Multiple Challenges for Hospital Sector: Key Thematic Areas 21
• Figure 1.1: Health Spending on Inpatient Curative Care, Across Countries, by Income Groups   21
• Operationalizing Reform: Practical—and Mixed—Lessons from the Field 23
• Reconsidering Care Models, and Scaling Reform 24
• Shifting Focus: Targeting Technical Interventions in Efficiency, Quality, and Integration 24
• Enhancing Quality: Opportunities from the Macro to the Micro Levels of Action 26
• Fostering Smarter Integration 27
• How This Report is Organized: Target Audience and Objectives, Structure, and Future Opportunities 28
• References 29
• SECTION 2 Efficiency as an entry point for hospital reform 31
• Chapter 2: Hospital Autonomy in Poland 32
• Key Messages 32
• Introduction 32
• Figure 2.1: National Health Fund Expenditures by Types of Services, 2003-2019 (PLN billion) 33
• Figure 2.2: Hospital Debts as a Percentage of GDP, 2003-2020 34
• Overview of Hospital Reforms in Poland 34
• Table 2.1: Overview of Hospital Sector Reforms in Poland 35
• Corporatization of Public Hospitals 37
• Table 2.2: General Structure of Hospital Provider Organizational Forms in Poland 38
• Figure 2.3: Ownership Structure of SPZOZs in 2020 (n=575) 39
• The Role of the Single Public Purchaser of Hospital Services 39
• Figure 2.4: Annual Spending on Health, All Sources 40
• Conclusion 42
• References 43
• Chapter 3: Sri Lanka’s Road to a More Efficient Health System: Linking Hospital Reform and Primary Health Care Strengthening 44
• Key Messages 44
• Introduction 44
• Figure 3.1: Sri Lanka: A Top Performer for Many Health Indicators (World Development Indicators, n.d.) 45
• Hospital Financing in Sri Lanka 46
• Figure 3.2: Per Capita Hospital Expenditure 46
• Figure 3.3: Proportion of Expenditure by Level 46
• Box 3.1: An Overview of Hospitals in Sri Lanka 47
• Long-Range Trends in Hospital Spending 47
• Figure 3.4: Pattern of Public Hospital Expenditure 48
• Health Care Seeking Behavior in Sri Lanka: Tilted Toward Higher Levels of Care 48
• Figure 3.5: Outpatient Visits Per Capita Per Annum 49
• Figure 3.6: Inpatient services* 49
• Figure 3.7: Outpatient Use by Level of Care 49
• Figure 3.8: Inpatient Use by Level of Care 49
• Table 3.1: Hospital Beds at Each Level as Share of Total Number of Beds in the Public Sector 50
• Figure 3.9: Bed Occupancy Rate in 2017 50
• Improving the Efficiency of Sri Lanka’s Hospital Sector 51
• Strengthening Hospitals and Primary Care Simultaneously 51
• Priorities and Policy Options 51
• Conclusion 53
• References 54
• Chapter 4: Day Surgery Center in the West China Hospital 55
• Key Messages 55
• Introduction 55
• Figure 4.1: Algorithmic Identification of Procedures Eligible for One-Day Surgery Proposed by Gilliard et al. (2006). 56
• Implementing a Same-Day Facility in China 56
• Implementation of the Day Surgery Center 57
• Protocols and Baseline Requirements 57
• Criteria and Procedures 57
• Results 57
• Number of Surgeries 57
• Length of Stay and Cost 58
• Patient Perceptions 58
• Conclusions 58
• References 60
• Chapter 5: Acute Geriatric Units: A Care Strategy for Aging Populations 62
• Key Messages 62
• Introduction 62
• What are acute geriatric units? 62
• What does it take to create an AGU? 63
• Implementation Facilitators and Barriers 63
• Evidence of AGU Impacts 64
• Factors that Influence AGU Effectiveness 64
• Conclusions 65
• References 66
• SECTION 3 Quality as an entry point for hospital reform 68
• Chapter 6: Improving Quality and Safety in Perioperative Care: The Enhanced Recovery After Surgery (ERAS) Program 69
• Key Messages 69
• Introduction 69
• Perioperative Care in Global Perspective 70
• Strategies to Improve Perioperative Care 70
• The ERAS Model 71
• Components of the ERAS Care Program 71
• Barriers and Facilitators to ERAS Scaling Up 71
• Challenges in Frontline Implementation 72
• Toward the Future: A Growing Global Network to Strengthen Perioperative Care 73
• Conclusions 73
• References 74
• Chapter 7: Regionalization as a Lever of Hospital Reform: The Case of Rural Obstetric Unit Closings in the United States, and Implications for Low- and Middle-Income Countries 75
• Key Messages 75
• Introduction 75
• Does regionalization of service delivery improve health outcomes? 76
• Regionalization of care through obstetric unit closings in the United States 77
• Figure 7.1: Maternity Care Deserts, 2020 77
• Figure 7.2: Access to Hospital-Based Obstetric Services for Rural Residents, Focusing on Highly Rural and Racially Diverse States, 2018 79
• Conclusions 80
• References 82
• Appendix: Levels of Maternal and Neonatal Care: Definitions, Capabilities, and Health Care Providers 84
• Chapter 8: Hospital Reform: Listening to Patient and Staff Experience, and Engaging the Broader Public   87
• Key Messages 87
• Introduction 87
• How can patient experience be used to improve health services?  88
• Current evidence for the impact of patient experience-based improvements on key outcomes  89
• Strengths and weaknesses of various approaches to the collection of patient and staff experiences 90
• Patient Experience Surveys and Measures  90
• Focus Groups  91
• Interviews  91
• Box 8.1: Resources for Patient Experience Research 92
• How Insights into Patient Experiences Can Be Used to Improve Care   93
• Community/Public Engagement  94
• Box 8.2: Feedback Mechanisms Available in One Coastal County in Kenya  94
• Figure 8.1:  Conceptual Framework Describing Processes of Receiving and Responding to Public Feedback (Kagwanja et al. 2023) 95
• Conclusions  96
• References  97
• Appendix: Resources for Patient Experience Research (with full bibliography) 102
• Chapter 9: Microlevel Interventions for Improving Hospital Performance 103
• Key Messages 103
• Introduction 103
• Methodology 103
• Results 105
• Workforce Strategies 105
• Tools 107
• Patient Engagement and Patient-Centered Care 108
• Conclusion 110
• References 112
• SECTION 4 Integration as an entry point for hospital reform 117
• Chapter 10: Leveraging the Principles of Networks and Learning Systems to Improve the Quality of Hospital Care: The Clinical Information Network in Kenya 118
• Key Messages 118
• Quality and Safety of Care in Hospitals 118
• Improving Quality of Care 119
• Networks and Learning Systems 119
• The Kenyan Clinical Information Network 120
• Table 10.1: Operationalization of the Principles of the Kenyan Clinical Information Network (CIN). 120
• Developing the Intangible “Software” of CIN 121
• Impacts of CIN 122
• What is CIN an example of? 122
• Conclusions 123
• References 124
• Chapter 11: Networks of Practice in Ghana, and the Role of the District Hospital 128
• Key Messages 128
• Introduction  128
• Country Profile  128
• The History of Facility Networks in Ghana  129
• Policy Dialogue and National Adoption of a Networks of Practice Strategy  129
• Figure 11.1: Configuration of Networks of Practice in a District (illustrative)  130
• Evolution of the Role of the District Hospital in Ghana  131
• Conclusions  131
• References 133
• Chapter 12: The Development of Medical Alliances in China 134
• Key Messages 134
• Introduction 134
• MA Models by Organizational Governance 134
• MA Models by Intensity of Integration 135
• Provider Payment 135
• Table 12.1: The Provider Payment in Four Typical MAs 136
• Regulation 138
• Principles and Performance Assessment 138
• Figure 12.1: The Four Fundamental Principles of Constructing MAs 138
• Figure 12.2: Comprehensive Performance Assessment Program for MAs 138
• Measurement and Evaluation 139
• Table 12.2: Measuring Criteria and Description for MAs in Different Dimensions 139
• Figure 12.3: The Evaluation Procedure: Five Steps 140
• Ongoing Reform 140
• Figure 12.4: An Improved Medical Service Governance Model 140
• Private Sector Involvement 141
• The Rollout of Medical Alliances 141
• Figure 12.5: Key Policy Documents for MAs 142
• Figure 12.6: Distribution of MAs in the 118 Pilot Cities and Other Cities 142
• Figure 12.7: National Distribution of MAs by Provinces and Cities 143
• The Impact of Medical Alliances 143
• Figure 12.8: The Ratio and Growth Rate of Outpatient Visits Between Hospitals and Primary Medical Institutions 144
• Figure 12.9: The Ratio and Growth Rate of Hospital Admissions Between Hospitals and Primary Medical Institutions 145
• Conclusions 146
• References 148
• SECTION 5 Cross-cutting considerations for hospital reform 150
• Chapter 13: The Evolution of First Referral Hospitals 151
• Key Messages 151
• Introduction 151
• Figure 13.1: Model of health system based on primary health care taken from the WHO Western Pacific Series No.4 District Hospitals: Guidelines For Development. 152
• Clinical Services at First Referral Hospitals 153
• Table 13.1: Clinical Service Categories as Proposed by WHO, DCP2, and DCP3 (English, Ngugi, and Smith 201; WHO 1992a). 153
• Declining emphasis in policy 154
• Trajectory in Low-Resource Countries: Country Case Studies 155
• Sri Lanka 155
• Figure 13.2: Diagram Illustrating the Health Care Structure and Shared Care Cluster Approach in Sri Lanka 156
• South Africa 157
• Nepal 157
• Trajectory in High-Income Countries 157
• Germany 158
• United Kingdom 158
• South Korea 158
• Conclusions 159
• References 160
• Chapter 14: Building a New Hospital: Key Questions and Considerations 162
• Key Messages 162
• Introduction   162
• Main Investment Considerations  163
• Needs Analysis and Service Strategy  163
• Modelling Needs and Capacity  164
• Viable and Evidence-Based Models 164
• Location Decisions, and Understanding the Wider Impact of Change  165
• Environmental Sustainability and Resilience 165
• Flexibility and Resilience  165
• Financial and Business Case Questions  165
• Box 14.1:  Critical Success Factors for Major Public Sector Investments  166
• The Planning Process  166
• Stakeholder Involvement  166
• Potential Pitfalls  166
• Evaluation  167
• Conclusions 167
• References  168
• Chapter 15: Essential Emergency and Critical Care 169
• Key Messages 169
• Critical Illness: An important Challenge for Hospitals 169
• Figure 15.1: Critical illness is the most severe form of acute illness. 170
• Figure 15.2: Three levels of critical care, graded by complexity and cost - and units where this care can be provided. 171
• Essential Emergency and Critical Care: A Feasible Approach for Impact 171
• Figure 15.3: EECC is the intersection of Essentialness and Critical Care 172
• Implementing Improved Critical Care 172
• Lessons to Guide Large-Scale Implementation of EECC 173
• Focus on Impact 173
• Learn from Other Cross-Cutting Initiatives 173
• Increasing Awareness and Implementation in All Settings 174
• The Role of Business Models 174
• Learning from Tanzania 174
• Next Steps for Maximizing Impact 174
• Conclusion 175
• References 176
• Chapter 16: Climate-Resilient and Sustainable Health Systems: Experiences from the Latin America and Caribbean Region  178
• Key Messages 178
• Introduction 178
• Definition of Climate-Resilient Health Systems: Challenges, Commitments, and Agenda  179
• Clinical Level  179
• Box 16.1: Low-Carbon Resilience, Clinical Level 179
• Network Level  180
• Box 16.2: Low-Carbon Resilience, Network Level  180
• System/National Level  180
• Box 16.3: Low-Carbon Resilience System, National Level 180
• From Operational Frameworks to Implementation: Cases from the Ground  181
• Furthering Hospital Infrastructure Standards  181
• Table 16.1: System Enablers and Present Challenges in the PforR financing in Colombia 182
• Table 16.2: System Enablers and Present Challenges in the Caribbean Project 183
• Integrating Health Systems in Disaster Risk Management  183
• Table 16.3: System Enablers and Present Challenges in CAT-DDO Operations in Colombia 184
• Lessons Learned and a Way Forward  184
• References 186
• SECTION 6 Moving Forward 187
• Chapter 17: Moving Forward: Urgency for Change in a Rapidly Warming Planet 188
• Taking a Systems Approach 188
• Urgency to Act 189
• Box 17.1: The World Bank at Work: Strengthening the Hospital Sector in the Caribbean through Resilient Networks of Care 190
• Conclusion 192
• Appendix: Review of Indicators for Tracking Hospital Service Delivery and Performance 194
• Commonly Reported Hospital Indicators 194
• Indicators Proposed for Mainstreaming 196