Scientific Justification of the Organizational and Functional Model of a Consultative-Diagnostic Center in the Context of Healthcare Reform

The dissertation is dedicated to the scientific justification of the organizational and functional model of a consultative-diagnostic center (CDC) in the context of healthcare system reform in the Russian Federation. The research analyzes the problems of development of consultative-diagnostic assistance, the state of health of the population, and the functioning of the healthcare institution network of Nizhny Novgorod Region, and systematizes the experience of consultative-diagnostic centers of various levels. A sociological research assessing the satisfaction of physicians of territorial healthcare institutions, CDC specialists, and patients with the quality of consultative-diagnostic assistance was conducted. Based on the obtained results, an organizational and functional model of a regional CDC was developed and tested; the strategy for its reform was justified; hospital-replacing technologies and methodological approaches to labor standards for medical personnel in new conditions were proposed.

Relevance of the Research

Large-scale political and socio-economic transformations taking place in Russia predetermine the necessity of searching for strategic directions for the development of domestic healthcare. The priority directions of state policy in the area of healthcare reform, defined by the "Concept of the Development of Healthcare and Medical Science in the Russian Federation" (1997) and the National Priority Project for the Protection of Population Health (2006), are: shifting the emphasis from the hospital stage of medical care to improving the accessibility and quality of primary medical care; increasing the efficiency of use of available material, personnel, and financial resources; expanding out-of-hospital and hospital-replacing forms of medical care for the population; developing high-technology types of specialized medical care, including consultative-diagnostic. The necessity of implementing these tasks is predetermined by a series of scientific research works (Shchepin O.P., 1997; Lisitsyn Yu.P., 1998; Denisov N.N., 2000; Vyalkov A.I., 2001; Starodubov V.I., 2001; Lindenbraten A.L., 2003; Kuchenko V.Z., 2003, 2005; Shchepin V.O., 2003 et al.).

A special place (Nikogosyan G.A., 1990; Tsypuri Yu.I., 1993; Serebrennikov V.A., 2002; Sveshninsky M.L., 2003) in ambulatory-polyclinic care is allotted to consultative-diagnostic centers (CDCs). The idea of their creation was determined by the necessity of applying precisely innovative in their essence, high-technology organizational forms of medical care delivery, which could significantly increase the efficiency and quality of medical service under conditions of limited financial resources.

The initial creation of CDCs as institutions-concentrators of complex informative diagnostic methodologies was corrected by practical life from the standpoint of unjustified determination of indications for the use of these methods and incorrect assessment of research results by physicians of the general network. The most rational and efficient use of diagnostic technologies of CDCs is possible only by highly qualified specialist physicians in various fields of medicine, who are directly familiar both with the research methods themselves and with the specialists performing them. Undoubtedly, a timely and expedient step at this stage was the organization within diagnostic centers of consultative departments staffed with experienced consultant physicians of various specialties.

However, the further necessity of expanding detailed and comprehensive patient examination, the introduction of minimally invasive diagnostic methods, and their transformation into resource-saving diagnostic-treatment and essentially therapeutic technologies increased the role of consultative-diagnostic centers as highly qualified clinical-diagnostic structures that do not require round-the-clock and, consequently, expensive patient stay in hospitals.

The organizational-technological capability (highly qualified personnel, availability of a complex of highly informative research methods allowing constant monitoring and timely correction of the diagnostic-treatment process when necessary, powerful equipment with high-technology apparatus, targeted patient selection, continuity at all stages of the diagnostic-treatment process), on the one hand, and wide demand among consumers, on the other hand, since the early 1990s have contributed to the gradual introduction and beginning of the development of hospital-replacing forms of medical care precisely on the basis of CDCs.

The accumulated experience and identified trends indisputably testify that throughout the entire period of operation of consultative-diagnostic centers, the introduction of minimally invasive diagnostic-treatment methodologies in out-of-hospital conditions ensures a substantial economic effect. However, the expansion of diagnostic-treatment capabilities of hospital-replacing forms of medical care on the basis of CDCs was determined rather by the current capabilities of the institution itself than by scientifically grounded approaches.

The development and functioning of consultative-diagnostic centers in the current period of adaptation of the healthcare system to market requirements is complicated and, in a number of directions, occurs spontaneously: there are no or are not adapted to present-day conditions normative (legislative) documents regulating the role and place of consultative-diagnostic centers in contemporary conditions; questions of quality control organization, marketing, economic management require further elaboration; scientifically grounded differentiated standards for medical personnel numbers and calculated labor norms are absent; moreover, the implementation of new technologies is also impeded by the unpreparedness of public opinion.

Thus, the practice and generalized experience of consultative-diagnostic center work over the past years have necessitated the introduction of adequate timely corrections into the previously implemented model of CDC functioning and have determined the relevance of scientific justification of the strategic development of consultative-diagnostic assistance to the population, which predetermined the choice of the topic of the present dissertation research.

Research objective: to develop an organizational and functional model of a consultative-diagnostic center in changing conditions of modernization of the healthcare system.

To achieve the stated objective, the following tasks were set and solved: 1. On the basis of analysis of the normative-legal base, sources of domestic and foreign literature, to generalize the existing experience of organization of consultative-diagnostic assistance, to identify problems of its development at the stage of healthcare modernization.

2. To provide a comprehensive characterization of the state of health of the population and functioning of the healthcare institution network of the region (on the example of Nizhny Novgorod Region).

3. To identify features of forming the volume and nature of consumption of medical services in consultative-diagnostic centers of the Russian Federation of various levels and to study the opinions of center directors on the role and place of CDCs in the healthcare system at the contemporary stage.

4. To conduct a sociological research on assessing the satisfaction of the population and physicians of healthcare institutions as consumers and CDC physicians as producers of medical services of the regional CDC.

5. To scientifically justify and implement an organizational and functional model of a regional consultative-diagnostic center in accordance with contemporary directions of healthcare modernization.

6. To conduct a comprehensive analysis of the effectiveness of implementing hospital-replacing technologies in the conditions of a regional consultative-diagnostic center with scientific justification of calculated labor norms for specific diagnostic and treatment methods.

7. To develop methodological approaches to labor standards in consultative-diagnostic centers in the conditions of implementing new medical-technical means and equipment.

Scientific novelty of the research consists in the fact that in the conducted research, for the first time:

• a comprehensive characterization of the state of health of the population of the region in interrelation with the functioning of the healthcare institution network of Nizhny Novgorod Region was obtained; with consideration of the comprehensive assessment of CDC activities, features of forming the volume and nature of consumption of medical services in consultative-diagnostic centers of the Russian Federation of various levels were studied; on the basis of studying the opinions of CDC directors on the role and place of centers in the healthcare system at the contemporary stage, the most relevant needs of CDCs, obstacles to further development, and possible ways to overcome them were identified and specified; a methodology for assessing professional satisfaction of physicians with the level of provision of specialized medical care in healthcare institutions of the territory of Nizhny Novgorod Region was developed and implemented; a comprehensive study of consumer opinions on the activities of the regional CDC was conducted, including the study of professional satisfaction of physicians of territorial healthcare institutions and patients as consumers, and physician-specialists of the regional CDC itself as producers of consultative-diagnostic services; an organizational and functional model of a regional CDC corresponding to contemporary directions of healthcare development was developed and implemented, its organizational advantages and disadvantages were determined, as well as prospects and threats of its future functioning; hospital-replacing forms using modern organizational and instrumental minimally invasive technologies, allowing to close the diagnostic-treatment process in a single cycle under CDC conditions, were tested and implemented in CDC activities; the medical-economic and social effectiveness of the new organizational-medical technology in the form of a short-term stay hospital (STSH) in the regional CDC compared to the traditional round-the-clock multi-profile hospital was determined;

• scientifically grounded calculated labor norms for individual diagnostic methods using new technical means (capsule endoscopy, endoscopic ultrasonography of the biliary ducts and pancreas, endoscopic ultrasonography of the esophageal, gastric, and duodenal walls) were developed;

• methodological approaches to labor standards for medical personnel of short-term stay hospitals in consultative-diagnostic centers were developed, tested, and implemented, including determination of labor time expenditures, personnel workload, and its numbers.

Scientific and Practical Significance

The results of the conducted research allowed the justification of the organizational and functional model of CDCs in new conditions of ongoing healthcare reforms.

Studying the opinions of CDC directors made it possible to identify the main problems of CDC activities in the Russian Federation and to develop priority directions for their development in contemporary socio-economic conditions.

A scientifically grounded methodology for assessing professional satisfaction of physicians of healthcare institutions referring patients to CDCs, combined with the results of a sociological survey of patients, makes it possible to obtain a comprehensive assessment of consumer satisfaction with the level and quality of medical services provided by CDCs.

The proposed organizational and functional model of a regional CDC makes it possible to ensure a higher level of quality of diagnostic-treatment assistance to the population of the territory at the contemporary level of development of the material-technical base and personnel composition of territorial healthcare institutions, ensuring at a higher level of quality modern highly informative methods of diagnosis and treatment, which substantially expands the capabilities of territorial healthcare institutions.

Recommended and tested organizational-medical forms that serve as the basis for implementing hospital-replacing diagnostic-treatment complexes, making it possible to provide necessary medical assistance in full volume at the ambulatory-polyclinic stage without reducing its quality and with a pronounced economic effect.

Methodological developments for personnel labor standards are effectively used in the medical-economic analysis of CDC activities.

Implementation of Research Results in Practice

The practical value of the scientific research is confirmed by the wide implementation of results and proposals of the completed work.

The results of the research are used in the activities of 5 regional consultative-diagnostic centers of the Russian Federation, which is confirmed by implementation acts.

The materials of the dissertation work are used in the pedagogical process at the Department of Public Health and Healthcare with a course in Economics of State Educational Institution of Higher Professional Education Moscow Medical Academy named after I.M. Sechenov, the Department of Public Health and Healthcare of State Educational Institution of Higher Professional Education Nizhny Novgorod State Medical Academy of Roszdrav, the Department of Preventive Medicine of the Central Professional Certification and Advanced Training Center of Nizhny Novgorod State Medical Academy.

Based on the results of the research, 37 scientific works were published, including 1 monograph, methodological recommendations "Labor Standards for Personnel of Diagnostic Centers" (Moscow, 2006), 17 publications are presented in publications included in the approved List of Periodical Publications by the Higher Attestation Commission.

Defense of Dissertation Materials

The materials and obtained results of the research were reported and widely discussed at the scientific-practical conference of the National Research Institute of Public Health "The Role of Healthcare in Protecting Public Health" (Moscow, April 22-23, 2004), the International Scientific-Practical Conference "The Role of Healthcare in Protecting Public Health" (Moscow, April 18-19, 2006), annual scientific-practical conferences of the Interregional Medical Diagnostic Association "Actual Problems of the Activities of Diagnostic Centers in Contemporary Conditions" (Moscow, 2000; Irkutsk, 2001; Moscow, 2002; Saint Petersburg, 2003; Nizhny Novgorod, 2004; Tula, 2005), at annual regional scientific-practical conferences (1999-2006).

MAIN PROVISIONS PRESENTED FOR DEFENSE

1. The deficit of financing in combination with low efficiency of resource use and the imbalance of the structure of medical care in Nizhny Novgorod Region determine the necessity of conducting reforms of regional healthcare, including determining the role and place of consultative-diagnostic centers in the course of these reforms.

2. The priority direction of healthcare system reform and shifting the vector of care delivery to the population from the hospital stage to the ambulatory-polyclinic one is the development of the network of consultative-diagnostic centers (CDCs) of the region. Consultative-diagnostic centers make it possible to ensure a higher level of quality of the diagnostic-treatment process for the population of the territory at an increasing level of development of the material-technical base and personnel composition of primary healthcare institutions, ensuring accessibility of modern highly informative methods of diagnosis and treatment for patients throughout the region through a substantial expansion of diagnostic-treatment capabilities of territorial healthcare institutions.

3. The implementation of high-technology minimally invasive diagnostic and treatment methods in a consultative-diagnostic center implies the inclusion in its structure of a short-term stay hospital (STSH), which serves as the basis for creating hospital-replacing diagnostic-treatment complexes using modern organizational and instrumental minimally invasive technologies, making it possible to close the diagnostic-treatment process in a single cycle under consultative-diagnostic center conditions.

4. Changes in the technology of the diagnostic-treatment process, the introduction of new diagnostic and treatment methods, new organizational forms of medical care delivery aimed at increasing the efficiency of their use determine the necessity of timely labor standards, including: determination of labor expenditures, workload, numbers, and optimal personnel proportions.