Topic 11

HEALTH CARE MANAGEMENT AND ADMINISTRATION COURSE Course Description This course is designed to prepare the student to work as a member of the health care team in a Primary Health Care setting and to implement the basic principles of Quality care. It also orients the student to basic principles of planning, implementation and evaluation of health care activities, and the management of resources including application of basic principles of health economics and approaches for cost containment. Goal of the topic: Orient the future PHC physician to his role in acting as a team leader efficiently managing the health facility, and adopting the principles of costeffective high quality care and adopting the concepts of cost containment Objectives of the Course By the end of this course, the student will be able to:

Identify management functions: planning, implementation, and evaluation

Describe the planning function and its components Define steps for community needs assessment Use data/information for situation analysis and identification and prioritization of health and healthrelated problems

List the basic implementation functions Define the principles of leadership and team building Define the evaluation function and demonstrate the ability to evaluate inputs, process, and outputs by the use of appropriate indicators

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Define quality and identify the dimensions of quality in health care

Define the three major aspects of health economics: financing, cost analysis, and cost-effectiveness

Identify the principles of cost analysis and define some measures for cost containment

These objectives can be rearranged as/ Intended learning 1. 2. Knowledge and understanding Professional and intellectual skills

outcomes (ILOs)and classified as :

General skills and attitudes Course Prerequisites This course supports other courses of Community Medicine. It can be given at any time of the course after the introduction, and statistics modules. It precedes the Health Systems and Health Services in Egypt Course Logistics This course is covered in 8 theoretical and 6 practical hours. It is mainly a classroom setting. Course Contents

Definition of management; and identifying its function as planning, Principles of management including: Management by objectives;

implementation, and evaluation functions. learning from experience; division of labor; convergence of work, substitution of resources, function determine structure; delegation; shortest decision path. The planning function
o

Definition of planning. The planning functions (Situation

analysis, problem identification and priority setting, objective setting,

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selection of alternative solutions, planning for resources, planning for monitoring and evaluation, planning for sustainability)
o

Types of planning as population / community based;

organization-based (institution-based) planning; planning periods starting from long range planning, yearly plans, three monthly implementation plans, down to weekly do it list; levels of planning and the importance of the middle level planning (District), and first level planning in the health facility.
o

Population-based / community based planning and its

application in planning for identifying health problems in the community; and prioritizing these problems. o Situation analysis: population-based and community-based.
o

Assessment of community needs: Definition of needs;

identification of needs (sources of information, techniques for identifying needs).

o o

Problem identification and priority setting in the community. Goals and objectives: Definition, setting SMART objectives

(Specific, Measurable, Attainable, Relevant, Time-bound) o Selection of interventions to solve community health problems: Criteria for selection

Organization-based management (Applied to a PHC setting):

o

Situation analysis: Strengths, Weaknesses, Opportunities, and

Threats (SWOT analysis). o Organization vision, mission, and objectives (apply to PHC)
o

Problem solving: Problem identification and definition, Analysis

of the root causes, identification of solutions and selecting the best solution, develop an action plan, implement monitor and evaluate. The implementation function:
o

Implementation functions include: Organizing, staffing and

human resource management, directing and leadership, coordination of work and team building, recording and reporting, monitoring and supervision)

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o Leadership: Definition of leadership, characteristics of effective leader, leadership skills, comparison between a leader and a manager o Team work: Definition, Characteristics of effective teams, Team process (Forming, storming, norming, performing), The PHC team. o Monitoring: definition, purpose, and methods o Supervision: traditional supervision versus supportive supervision

The evaluation function:

o

Definition of evaluation, components (evaluation of inputs,

process, outputs, and outcome) o Conducting evaluation ( describe the program / organization activities, describe goals and objectives, identify indicators, develop evaluation design, collect data, analyze and interpret, utilize results for decision making for corrective actions). Quality management:
o

Definitions: Quality, quality assurance, quality control, total

quality management, continuous quality improvement CQI) o Dimensions of quality in health care ( accessibility, appropriateness, effectiveness, equity, efficiency, support for health care providers). o Quality improvement tools (Statistical and qualitative methods) o Steps for CQI o Auditing o Accreditation (The present system for accrediting Family Health Units) Health economics: o Definition and major components (Financing, cost analysis and cost effectiveness)
o

Financing health care (governmental financing, user fees, health

insurance, etc.)

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o Present systems of financing health care in Egypt with emphasis on the family health fund, and the evolving national health insurance system and implementation in the Family Health Model. o Cost analysis: Cost categories (Fixed costs category I, Direct cost category II, and capital cost category III); calculation of unit cost. o Cost-effectiveness analysis: Indicators used to measure the effectiveness of health improvement (Adjusted life years: Concepts of Disability Adjusted Life years DALYs, and Health Adjusted Life Years HALYs); steps for cost effectiveness analysis.
o

Cost containment: The rising cost of health care; measures for

cost containment on the demand side and the supply side; costeffective public health measures; essential clinical services. Egypt basic benefit package and basic promotion/preventive package. Teaching Methods Theoretical: Lectures including large group discussions Practical:

Case studies Exercises on problem solving, priority setting, use of quality

improvement tools, decision making for selecting best solutions, costeffectiveness analysis

Practicing brain storming and decision making technique

Learning Materials Reference Department Book Case studies Relevant publications

Course Assignment At the start of the course students are asked to prepare a plan to address a certain community health problem or an organizational problem. They can

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work in teams and present the assignment at the end of the module during the practical sessions. Assessment Methods

Follows the assessment methods described in the guide's

introduction for the whole course. As part of formative or summative assessment. The practical will be assessed by the tutors in a formative approach. A proportion of the midterm grade will be allocated to the class performance. Attendance Fourth year medical students Course Schedule 8 hours classroom teaching and 6 hours practical training These lectures are entry to health system, health care and administration. Teaching session plan The course is 8 theoretical hours and 6 practical hours. The theoretical is presented as session plans for each one hour. It can be modified according to the time table of each faculty and the time allocated for each lecture. Teachers could arrange the teaching slides according to the following tables: Introduction, Definitions and Principles of Management, and the Planning Function (First hour) Learning Activity Introduction team; Present slide 2: Goal of the topic, Egyptian Community Medicine Association 68 Introduce yourself, Present slide 1: Description of the topic and its Time 5m

importance for the physician as a member of the PHC

Slide 3: Objectives of the topic 10 m

Slide 4: Objectives of the lecture Definition of management Ask 2 students to express their concept of what Comment and present slide 4 & 5: Definitions of management means to them. management and explain effectiveness and efficiency. Principles of management Explain the principles of management: slides 7 14 giving examples for each of the principles Management cycle / Planning function Present slide 15 for management functions cycle: Ask 2 other students to give their concept of Present slide 16: Definition of planning, Present slide 17: the planning functions Present slide 18: Types of planning as planning, implementation and evaluation for re-planning. planning.

15 m

10 m

6m

population/community-based planning and organizational planning. Present slide19: Planning periods. Present slide 20 on the planning periods and its Comment that every individual in his work have to do

relation to the management level: top, middle and first level some sort of planning.

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Situation Analysis Present slide 21(same as 17) and tell the students you are going to discuss the first planning function which is situation analysis. Present slide 22: Information needed for populationbased situation analysis as: socioeconomic and development policies, socioeconomic, demographic, epidemiologic, and health and other resources situation analysis. Present slides 23 27 explaining each of the above Present slide 28: Items included in community-based components situation analysis

14 m

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The Planning Function (Cont.); Assessment of Community Needs and Resources (Second hour) Learning Activity Present lecture objectives: slide 1 Tell the students that as a PHC physician s/he is responsible for planning to improve the health of the community and address their health problems through mobilizing community involvement and their full participation. Community needs assessment Tell the students that assessment of community needs and resources is a form of situation analysis at the community level. Ask 2 students what is meant by needs Present slide 2: Definition of needs Present slide 3: definition of resources Re-emphasize that needs assessment conducted 5m Time 5m

with the participation of the target population strengthen community commitment to their participation in solving their problems. Slide 4: Why assessment of community needs Slide 5: How would services intended to help

people be most effective, and the importance that communities identify their own problems, become interested in solving them and have confidence in their capabilities in solving them Slide 6: Information required for identification of needs and resources Slide 7: Techniques for identifying needs, and Slide 8: Needs assessment ends up by identifying 15 m obtaining information. Who needs what as defined by whom Problem identification on community basis: Slide 9: Problem definition Egyptian Community Medicine Association 71 10 m

Slide 10: Causes, underlying and contributing Select a public health problem and ask students to

factors, Problem tree think about the causes, underlying and contributing factors (e.g. diarrhea, protein energy malnutrition, etc). Draw the problem tree on the board Priority setting Slide 11 & 12: criteria for selecting priority 10 m problems on community basis Goals and objectives: Slide 13: Types of objectives Slide 14:Definition of goals. Select a problem e.g. 5m

malnutrition and a program e.g. MCH and ask two students to mention the goal Slide 15: Give examples of good objectives Mention that at this stage we have to think about

indicators to measure achievements of objectives, mention examples, present in slide 16 Selection of solutions / interventions Slide 17: Criteria for selection of the solution / Slide 18: Decision matrix for selection of solutions / Give examples of appropriate solutions for a interventions interventions selected priority problem 10 m

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Organization based management (Applied to a PHC setting) (Third hour) -

Learning Activity Present lecture objectives: slide 1 Slide 1: Concept & definition of an organization Slide 2: Organizational principles Slide 3: Management functions of an organization; Slide 4: Job descriptions. Give examples of Job

Time 15 m

organizing, coordinating, directing, motivating controlling. description for different members of the PHC team Organization Vision and Mission Slide 5: Organization Vision. Ask 2 students to give Slide 6: Present an example of vision statement Slide 7: Organization Mission. Ask 2 students to a vision statement for PHC.

10 m

give a mission statement for PHC / Family practice Slide 8: Present an example of mission statement. Strategic planning in an organization Explain that strategic planning considers where are we and where we want to be (Slide 9); the difference represent the gap, reflecting the needs, or the problems. Where we are is the situation analysis. It is done through SWOT analysis which stands for Strengths, weaknesses, opportunities and threats. (Slide 10) Ask students to give from their own point of view points of strengths, weaknesses, opportunities and threats of a PHC center. Present slide 11 giving examples of SWOT Problem solving Slide 12: Steps for problem solving include: Identify and define the problem (the gap between what is and what should be), discover and analyze causes of the problem, identify possible solutions, select the best solution, make an action plan, implement the solution, Egyptian Community Medicine Association 73 15 20

monitor and evaluate. For the identified gaps / problems we are going to look for the root causes (mention that this is going to be discussed with quality tools)

The implementation function, leadership and team building (Fourth ) Learning Activity Present lecture objectives: slide 1 Slide 2: Components of the implementation 25 m function, and comment on each of the components Leadership Slide 3: Definition of leadership Slide 4: Continuum of leader decision-making Slide 5: Characteristics of an effective leader 25 m Time 10 m

authority Slide 6: Difference between leaders and managers Team building Slide 7: Definition of team work Define team members in different health care Slide 8: Characteristics of effective teams Slide 9: Team process (forming, storming, norming, Slide 10: Team problems Slide 11, 12: Solving team problems

settings, PHC, clinics, etc.

performing)

Monitoring, supervision and evaluation (Fifth hour)

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Learning Activity Present lecture objectives: slide 1 Monitoring Slide 2: definition of monitoring Slide 3-5: Purpose of monitoring inputs, process,

Time 10 m

outputs Slide 6: Methods of monitoring Supervision Tell students that while monitoring is for all Slide 7: Definition of supervision Slide 8: Objectives of supervision Slide 9: Basic functions of a supervisor Slide 10: Methods of supervision Slide 11: Definition of supportive / facilitative Slide 12: Differences between supportive Slide 13: Role of the supervisor as facilitator, resources, supervision is intended for human resources 20 m

supervision supervision and traditional supervision trainer, coach Slide 14: Definition and role of a coach Evaluation Slide 15: Definition Slide 16: Components (evaluation of inputs, Slide 17 : Conducting evaluation Tell the students that evaluation needs indicators. 30 m

process, outputs and outcomes)

And give examples for indicators used to evaluate different programs

Quality Management (Six hour) Egyptian Community Medicine Association 75

Learning Activity Present lecture objectives: slide 1 Slides 2 - 5: Definition of quality terms: Quality assurance, quality control, total quality management (TQM), continuous quality improvement (CQI) Dimensions of quality in health care Explain each of the following (slides 6 11) Accessibility Appropriateness Effectiveness Equity Efficiency

Time 5m

5m

Support for health care providers Perception of quality by the health care service triad (slides 12 15) Community Health team

5m

MOHP TQM model slide 16: Well designed systems of work Effective functioning teams Use of quality tools

10 m

Elements of TQM slide 17: The customer (external and internal, teamwork, scientific approach) Quality improvement tools slide 18: Statistical and qualitative methods Rapidly mention few words on each Display in slides 19 21 the control chart, run chart, 20 m

and Pareto chart, and mention that these will be part of the practical Explain the process of brain storming for decision Display slides 25 27 for some qualitative methods: making in eliciting qualitative information (slides 22 24) flow chart, fish bone, force field analysis. And mention that it will be demonstrated in the practical

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The ten steps for quality assurance process: slides 28 - 30 Auditing and accreditation Slide 31: Definition of auditing Slide 32: Auditing as a problem solving process Slide 33: Definition of accreditation Slide 34-35: the present system of accreditation of the

5m 10 m

family health units Health Economics (Seventh hour) Learning Activity Present lecture objectives: slide 1 Slide 1: Definition Slide 2: The three major aspects of health 20 m Time 5m

economics Financing health care Slide 3: Major methods for financing Slide 4 & 5 : Government financing : sources and Slides 6: User fees (user charges) potential Slides 7: User fees (user charges) potential Slide 8: Suitability of services to users fees Slide 9: Types of health Insurance Slide 10: Social insurance / government insurance Slide 11: Private health insurance Slide 12: Health maintenance organizations Slide 13: Other financing mechanisms: Community

allocation advantages disadvantages

financing, employer financed systems, charity and voluntary contributions Present systems for financing health services in Egypt Slide 14: The multiplicity of systems Slide 15 & 16: The family health fund 20 m

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Cost analysis Slide 17 -19: Classification of cost by inputs: Slide 20: Simple classification by Capital cost and Category I, II, & III recurrent cost Cost-effectiveness analysis (Snap shot) -

5m

10

Slide 21: Its use in selection of alternative solutions Slide 22: Indicators used to measure the Slide 23 & 24: Disability adjusted life years (DALYs) Slide 25: Health adjusted life years (HALYs)

effectiveness of health care in health improvement

Health Economics (cont.) Cost Containment (Eighth hour) Learning Activity Present lecture objectives: slide 1 Definition and concepts of cost containment (slide 15 m 2 & 3) Causes of the rise in health care spending Ask 4-5 students about their concept of the causes Present slides 4 & 5 on causes of rising health care of rising costs spending Allow for addition from the students Actions / measures for cost containment: Slide 6: Measures on the demand side: user fees, Slide 7 & 8: Health insurance and rationalized use Slide 9: measures of cost containment on the education to rationalize use of service supply side: Identify most effective actions, training at all levels, appropriate technology, rationalized use of drugs, reform health insurance Slide 10 & 11: Rational use of drugs 5m 15 m Time 5m

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Slide 12: Essential drug list as a method for 20 m

rationalizing drug use Cost effective services Slide 13 & 14: International concepts of public Slide 15 & 16: International concepts of essential Slide 17 19 Egypt promotive / preventive Slide 20 23: Egypt basic benefits package health services that are highly cost effective clinical services package

Practical training
(Six hours) Practical Setting The practical sessions are given in groups of 20 per tutor. This topic is covered in three practical sessions each of 2 hours. Students receive the material at the start of the theoretical course. They are asked to go through the material before coming to the class. Students work in groups of five to reach answers for the questions posed by the case study and exercises. The expected learning outcomes from this practical that, student should be able to: 1. 2. 3. 4. 5. 6. 7. 8. Do a situation analysis Identify and prioritize health problems Define the causes and contributing factors of a community Describe root causes a performance-related problem Write SMART objectives Practice brain storming to select appropriate solutions Identify indicators for evaluation Each group will present a report with the final product of the

health problem

class work to be graded.

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Case Study: Allow students to construct their own data sheets from the following information -The village xyz has a population of nnnnnnnnnn. The families in the area are nn. The services available in the village include: A family health unit belonging to the MOHP is keeping family folders for n families. -Other developmental resources include: A community development association with limited activity. Two private practicing physicians. An NGO working in the field of development. A primary and a preparatory school are present. -Illiteracy rate among males 10Years of age and older is 25%, and among females is 65% and Consanguineous marriage is very high. -The village has potable water, but no sewage disposal system, nor a safe way for solid waste disposal. Give some health related data are as follows: The population is = nnnnnnnnnn Number of births = Number of deaths = Infant deaths = Women in the child bearing period = Contraceptives prevalence rate (CPR) = Vaccination coverage by all vaccines = The main causes of death are: Cardiovascular diseases, and respiratory problems The main causes of infant deaths are: Births attended by the center are only half of the total births Number of mothers attending ANC represent 60% of the expected pregnancies The outpatient clinic is attended by 15 -20 persons per day. Most of them are females. The main chronic diseases diagnosed among males are: Hypertension, Type II Diabetes. Females suffer in addition, obesity and genital tract infections. ** From the available data students are asked to: Profile the present situation Egyptian Community Medicine Association 80

Exercise 1:

Identify the main health problems Select two problems and draw a problem tree to identify the Formulate objectives Select interventions Determine the methods and indicators for evaluation

causes and contributing factors

The family health unit has lately experienced a drop in the number of health care consumers of the family planning services. ** Draw a fishbone diagram to elicit the possible root causes for this problem. What are possible interventions needed to solve this problem? Exercise 2: An exit questionnaire for 150 clients revealed the following causes for not being satisfied: Cause Number of times mentioned Unit not clean 20 Drugs not available 50 Deficiency in giving information 75 Providers not nice 45 Long waiting time 15 Unavailability of doctors 15 Cost of service 30 **Draw a Pareto chart, Identify the vital few causes you are going to work on

Practical Training Sessions' Plan Practical 1: Community based planning and evaluation (Two hours) Learning Activity Time

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Introduce the objectives of the practical training Describe the process of conducting the training and

10 m

divide the students in small groups Describe the principles for group work Describe the steps for brain storming 40 m 10 m

-Ask the students in each group to read the case study (5 m) -

Each group will perform a situation analysis (15 m) Group presentations with no comments (10 m) Invite comments to complete the picture of situation

analysis (10m)

Each group will write a list of problems identified from Present the group list and come up with a

20 m

the situation analysis (5 m) comprehensive list (15m)

Ask each group to develop a priority list Present the priorities for each group Each group will select a problem different from the Define the causes and contributing factors of a Group presentations and discussions

10 m

20 m

others to work on community health problem

Summarize the work of the session

10 m

Practical 2: Community based planning and evaluation (cont) (Two h)

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Learning Activity Introduce the work of the day (2 m) Each group revises the problem they selected in Develop SMART objectives the last session, their causes and contributing factors

Time 15 m

Present and discuss Each group uses brain storming technique to select 25 m

best solutions using decision making criteria / matrix (to be provided as a handout) Present and discuss Group work: From the sum of all the groups, what 20 m

will be the interventions recommended to be implemented by the family health unit Group presentation and discussion Present the principles of evaluation, and the 5m 25 m 20 m 10 m

evaluation grid (to be provided as a handout) Each group develops the indicators for evaluation and completes an evaluation grid Presentation of group work and discussion Summarize the work of the session and give a date to collect the assignment on the community plan finalized in the two sessions

Practical 3: Organization based management (Two hours) Learning Activity Introduce session objectives Group work: Do a SWOT analysis to a PHC unit Group presentation and discussions Present exercise 1: Group work for root causes Presentation and discussion for root causes Group work for interventions Presentation and discussion for interventions Present exercise 2 Individual work to draw a Pareto Presentation of a sample Large group discussion Egyptian Community Medicine Association 83 25 m 25 m Time 5m 15 m 20 m 20 m

Summarize the practical work and ask for verbal /

10 m

written evaluation

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