0   MINISTRY OF EDUCATION AND TRAINING - MINISTRY OF HEALTH NATIONAL INSTITUTE OF HYGIENE AND EPIDEMIOLOGY TRUONG QUY DUONG CONSTRUCTION AND EFFECTIVENESS EVALUATION MODEL TECHNICAL TRANSFER TRAINING OF HOA BINH PROVINCE HOSPITAL FOR DISTRICT HOSPITALS Specialization: Public Health Code: 62 72 03 01 SUMMARY OF PUBLIC HEALTH DOCTORAL THESIS HANOI - 2012 0   This thesis was completed in: NATIONAL INSTITUTE OF HYGIENE AND EPIDEMIOLOGY Supervisor: 1) Prof. Dr. Dang Duc Phuc 2) Ass. Prof. Dr. Trinh Hong Son Review 1: Prof. Dr. Pham Huy Dung Review 2: Ass. Prof. Dr. Le Van Bao Review 3: PhD. Do Hoa Binh The thesis will be presented before Institute Thesis Expertise Board, held at the National Institute of Hygiene and Epidemiology At on / / 2012. The thesis could be found at: - National Library - Library of Institute of Hygiene and Epidemiology 0   ABBREVIATIONS AND ACRONYMS HI : Health Insurance PT : Patient DT : Doctor HO : Hospital GH : General Hospital HS : Hospital Staff DLI : Doctor Level I DLI, DLII : Doctor Level I, Doctor Level II HC : Health care ED : Education EIT : Efficiency Index of Intervention HB : Hospital Bed CL : Clinical INT : Intubation GC : General Clinic HE : Health NE : Neonatal AV : Average TO : Total HS : Health Station TE : Test 1   BACKGROUND One of the pressing issues of Vietnam's health sector was that health care system faced difficulties and shortcomings, such as distribution of the hospital system is not balanced, especially the last treatment line all located in large cities; There were disparities in healthcare quality between upline and downline; qualifications of medical staff especially the facility line has not met people's needs The above situation did not only affect the quality of patient care, also to hospitals were suffering from overload in patients with increasing levels of stress. General Hospital of Hoa Binh province was responsible for clinical activities for people in the region, subject to clinic in HO are mainly people of ethnic minorities and the poor. In recent years, HO is always in a state of overload, capacity utilization of hospital beds high (125-150%). Status of district HOs to transfer PT to the provincial clinic HO and PTs over-line occupied high percentage. One of the causes is health staff qualification, ability of the district HO to meet the clinical needs is still restricted. From the reasons above, we researched the subject to get two objectives: 1) Describe the situation demands and the ability to provide medical services for inpatients of two hospitals in Tan Lac and Kim Boi district, Hoa Binh province (2006-2008). 2) Develop and evaluate the initial effectiveness of technical transfer training model of the provincial hospitals to improve medical care for district hospitals. * The new contribution of the thesis: Identified situation of in-patient clinical needs of the people in two district Tan Lac and Kim Boi was high, while the ability to provide inpatient services of district general clinic is limited about professional competence. In order to meet the increasing clinical demand of the district HO for the people in the local. The highlight of the thesis was that built and implemented the provincial hospital transfer techniques training model to enhance the capacity for district GHO, focused on a number of fields such as essential newborn care, external trauma ( the bone surgery), other products (caesarean section, surgical diseases of the uterus, ovary), anesthesia resuscitation, CPR. Effectiveness of post-intervention: the average duration of treatment (day) /1PT decreased. Number of patients hospitalized, number of surgeries, tips markedly increased, rate of patient transferred up-line and over-line significantly reduced; neonatal care capacity, the bone surgery, caesarean section, uterus pathology surgery, ovaries surgery were improved. * Layout of the thesis: The thesis consisted of 149 pages (35 results tables, 2 graphs, 1 figure). The thesis structure into four chapters: Introduction 2 page; Chapter 1 - Overview 38 pages; Chapter 2 - Subjects and Methods 24 pages; Chapter 3 - 39 page research results; Chapter 4 - Discussion 45 pages; 2 pages Conclusions and Recommendations 1; Ref: 117 documents (84 Vietnamese, 33 English), which has 76 material (65%) published since 2005. 2   Chapter 1: OVERVIEW 1.1. Situation needs and ability to provide inpatient services KCB BV system of Vietnam. As defined by the World Health Organization (WHO): "Hospitals are an integral parts of a social organization and health, its function is comprehensive health care for people, both prevention and treatment; outpatient services of the hospital to reach out to the family and living environment. HO is also a center for training health staff and sociological research. " 1.1.1. Characteristics, roles, functions and duties of hospitals in Vietnam Vietnam HO Systems has formed and developed over 100 years in the different conditions of economic, social, political, and had an important contribution in the protection and health care for people. However, our country HO system also showed some survival should be overcome as the distribution of hospital beds was not balanced between the regions; average number of hospital beds per 10,000 population was low, leading to the overload at the hospital. Most HOs had a bed capacity utilization was too high (103-120%), in which the central hospitals line (>120%) and provincial and district HOs were> 110%, the average of inpatient days was 7-14 days. * Functions and duties of HO: Hospital was the basis clinical facility had clinical function and health care for patients. Duties: - Health Care was the main function, clinical services could be divided into various categories: diagnosis and treatment, inpatient and outpatient, … in which inpatient treatment was the most essential function. - Staff training: HO was the basis for training practice health staff, more specialized training such as general doctor and specialists, nurses, nursing care, midwives, medical technicians,… upline hospital was responsible for training and technology transfer for the downline HO through line direct system. -Line direct - Support health system: HO System was organized according to their technical. The service was responsible for the downline technical direction. In addition, BV also have to perform many important tasks such as scientific research; Prevention; International Cooperation; Economic Management, 1.1.2. Technical distribution in clinic Vietnam Hospital System was divided into 3 levels: county / district HO, provincial/ city HO; central HO. Clinical and technical distribution of goal-oriented to infrastructure investment and technical development and clinical decentralization to increase the treatment efficiency of HO. - Provincial/ City line: The facility provided services clinic with specialized technical, professional, meet most people's health care needs in localities provinces. 3   - At the district/ county line: The clinical facilities provided inpatient services with the basic techniques, solving a number of emergencies and common illnesses from community or from the health stations move up . 1.1.3. Current status of medical services provided to meet the clinical needs of the people * Organized providing health care services: The State Hospital played the leading role in providing inpatient clinical services. Average: 24 patient-beds /10.000 people. Since 2002, the number of patient beds /10.000 people has tended to increase. Number of hospital beds in 2010 reached 20.5 beds/10.000 people, higher than the average in low- income countries (12) and middle-income (16), higher than Indonesia (6), Philippines (13), Malaysia (18), but lower than Thailand (22) and China (22). The hospital has increased the availability of clinical services. In 2009, the whole health sector has made more than 2 million surgeries (level 3 or higher), up 8% from 2008. Total number of new clinical techniques was done in the hospital reached 3062 times (up 27.3%), total number of new clinical techniques were deployed to reach 2,481 times (up 52.2%). * Ability to access and clinical service use level of the people: Regarding the hospitalization, the period 2002-2006, on average, every 100 people with about 9 times to enter the public HO for inpatient clinic/ year. In two years (2008, 2009), this ratio had increased to 12 times/100 people. This rate was quite high compared to other countries like the U.S. (11.7), Canada (7.8), Singapore (9.39) were the countries with older population, with the incidence of chronic diseases was higher. The rate of hospitalization in the State HOs of minority ethnics (53.5%) was lower than the Kinh (85.9%). 1.1.4. The challenge for HO in clinical service providing - Number of HS for clinic is lacking compared to payroll norms and actual needs. Norms HS in clinical sector were in accordance with Joint Circular No. 08/2007/TTLT-BYT-BNV. Distribution of HS unevenly between regions and between rural and urban areas, especially mountainous and remote areas lacked HS drastically, clinical service quality gap between regions has the distinct difference Health human resources which were not in sufficient quantity to have unreasonable shift by three trends from disadvantaged areas to areas with economic conditions - social development. So lack of HS was common condition in the downline health facilities, especially in rural, regional and remote areas. - The pattern of disease has been much changed: The model of disease in our country today alternating between infectious disease and infection. - Overload exacerbated HO: Currently, the country's number of beds to 17 patient beds /10.000 people, much lower than some countries in the region. The 2-3 patients/1bed situation was common in many provincial hospitals, especially the central hospital which bed capacity was up to 120-160% 1.2. BV model to participate in training and technology transfer services for medical facilities KCB lower 1.2.1. On the world In most developed capitalist countries, HO provided inpatient clinical services which were private. HOs competed with each other to attract patients to recover capital 4   and high profitability. Therefore, the large private HOs prestigious training technology transfer for the lower HO (small HO) only took place in nature orders the contract "to buy, sell," but not the mandatory provisions such as in Vietnam. However, private hospitals had professional training programs and technical support for medical facilities in the community and directly participate in the activities of community health care. 1.2.2. Model upline hospitals support downline hospitals to improve the quality of clinic in Vietnam To overcome the overload situation for upline HO, the Ministry of Health issued Decision 1816/2008/QD-BYT approving the project " Appoint professional staff rotation from upline HO to support downline HO to raise the quality of health care activities "(referred to as project 1816), with 3 objectives: (1) Improving the clinical quality of the downline HO, especially in mountainous, remote areas lacked health staff (2) Reducing overcrowding on routes to hospitals, particularly central hospital, (3) technology transfer and on-site training to improve skills for health staff downline. The appointment of professional staff rotate from upline hospital to support the HO downline in order to improve the quality of clinic had an important implications in the protection, care, improve people's health, proceed to the fairness in health care in different regions throughout the country and simultaneously training on-site staff resources in place with professional qualifications meet the needs of local people. The result in the internal rotation of the provinces/cities: 31/41 provinces had alternate plans of district support staff, 26/41 had planned to send officials to support the communal health stations. There were 464 officers turns were sent to support the 186 HO/ General district clinics, 543 officers were sent to support the 452 commune health stations. 1.2.3. Some studies about the rotating support staff for lower to improve clinical quality Grobler and colleagues studied "solution to increase the percentage of health staff working in rural and less health services", in 1996 - 2007 showed the result of the appointment of medical staff to work in the rural areas. Henderson and Tulloch (1998-2007), studied "Policies to encourage and retain health staff in Asian and the Pacific countries". Lehmann and colleagues "Policies to attract health staff working in rural and remote areas in the low and middle income" in 1997 - 2007, showed rotating staff in developing countries was necessary. Le Quang Cuong, Vu Thi Minh Hanh and colleagues (2009) made "Research 9 months to implement the proposed solutions to improve the Scheme in 1816", showed the implementation of Scheme 1816, it needed to have the solution to ensure the sustainability and effectiveness of the Scheme. Chapter 2: SUBJECTS AND METHOD 2.1. Subjects, materials, location, study period 2.1.1. Study subjects - Study subjects: All patients on the inpatient full medical records at two General Clinics Tan Lac and Kim Boi in 2006 - 2010 (total of 86 381 patient turns). Health staff group directly involved and provided training services (TR)for improving clinical 5   capacity GH of Hoa Binh province. Hospital leaders group, departments, and office staff, medical personnel were sent for training, technical transfer of the district GH. 2.1.2. Materials Research - Medical records of all patient were referral, overline from Tan Lac and Kim Boi GH to Hoa Binh province GH from 2006 - 2010. - The general reports analyzing data related to clinical activities, training, direct line of General planning department, Direct line bureau and some offices relevant to Hoa Binh province GH in the years 2006-2010. - Reports of inpatient clinic and professional activities of the two GH annually in 5 years (2006-2010). 2.1.3. Location, time studies - Location of study: In Hoa Binh province GH and two district GHs Tan Lac and Kim Boi, Hoa Binh province. - Research Time: 5-year study. In which: Description study (01/2006-12/2008); Intervention study (01/2009-12/2010). 2.2. Research Methods 2.2.1. Study Design Design cross-sectional descriptive study, combining quantitative research with qualitative analysis of secondary data and intervention studies had compared before and after intervention (no control group). 2.2.2. The study described the actual need and ability to provide clinical services at district GH - Select two GHs districts ( Tan Lac and Kim Boi GH district) with the criterion is the number of patients and referral rate, overline and referral rates of patients with different diagnosis with Hoa Binh GH high. - Key indicators described the status and needs the ability to provide inpatient services of District GH: Number of clinic in average/1000 people / year; Some personal characteristics (ethnicity, age, condition economic, health insurance card, ), PT referral, overline rate, the disease had a high referral rate, the percentage of patients with differential diagnosis upline and downline; bed use rate; treatment day average; the rate of implementation techniques in accordance with regulation 2.2.3. Develop a model training of technical transfer in Hoa Binh province GH to enhance medical capacity for district GH. * Pursuant to build the model: - The legal documents related such as: HO Regulation; Decision No. 1816/QD- MH the Ministry of Health, Decision of the Ministry of Health issued the regulations of technical distribution and list of medical technique for HOs; Circular of the Ministry of Health Regulated Health staff to annually attend the training course constantly - Based on survey results about demand situation on the ability to provide medical services of two studied district GHs. Training needs of clinical capacity improvement of two Tan Lac and Kim Boi district GHs. Qualifications and skills to practice the technical services of the medical staff in two Tan Lac and Kim Boi district GH; capability of technology transfer training of Hoa Binh province GH * Model building content: Completing direct line network to manage, operate and carry out the training activities. Construction training management cycle and the 6   specific steps of the training cycle; The contents and training activities of technical transfer; indicators to assess the effects of model * The training technology transfer; Focusing on a number of fields such as essential newborn care, the bone surgery, caesarean section, operating on the surgical pathology of the uterus, ovaries to improve the quality of emergency and treatment for patients in district GH. The primary active intervention of the model was the province GH organized training courses of technical transfer mainly in province GH and a part of the district. - The Effectiveness access indicators of intervention: measured index that had investigated the situation (before intervention), before-after comparison, some indexes was calculated efficiency index. Judged by the results of monitoring, evaluation during and after training, combining interviews, focus group discussions with the objects 2.2.4. Evaluation of research * Review of HO professional personnel: As compared with the payroll norms first line: polyclinic facilities Class III standards prescribed in the Circular No. 08/2007/TTLT-BYT-BNV dated 05/6/2007 of the joint MOH-Ministry of the Interior Ministry guiding to the payroll in the State health facilities. * Evaluated the professional activities of the district GH: Evaluation indicators such as: The bed occupancy rate, average duration of treatment (days), patient referral rate, overline rate, the percentage of patients with other diagnoses with provincial GH According to the "Hospital Management" of the Ministry of Health published in 2001. Assess the ability to perform a number of techniques in treatment of district GHs under the "Decision No. 23/2005/QD-BYT of the Ministry of Health regulating the distribution of technical and engineering list. Evaluation of treatment results overall, the results of surgical treatment of bones, caesarean section, operating on the surgical pathology of the uterus, ovaries and result emergency care for treatment of neonatal diseases. Chapter 3: RESEARCH RESULTS 3.1. Situation needs and ability to provide inpatient services of two Tan Lac and Kim Boi district GHs, Hoa Binh province (2006-2008) 3.1.1. Situation needs of inpatient medical care in two district GHs Table 3.1. Demand for inpatient medical care of patients at two Tan Lac and Kim Boi GHs, Hoa Binh province in three years (2006-2008) Year Index District Kim Boi Tan Lac 2006 Population 109958 74549 Total times of inpatient clinic in district GH 7124 6359 Times of inpatient clinic average/100/yea r 6.5 8.2 2007 Population 111295 75455 Total times of inpatient clinic in district GH 9673 6357 Times of inpatient clinic average/100/yea r 8.7 8.4 2008 Population 112647 76372 Total times of inpatient clinic in district GH 10777 8859 Times of inpatient clinic average/100/yea r 9.6 11.6 7   Count the times of inpatient clinic average/100/year for 3 years (2006-2008) has ranged from 6.5 to 9.6 (Kim Boi) and from 8.2 to 11.6 (Tan Lac ). * Some features of inpatients at two hospitals: Muong ethnic majority (86.42% in Kim Boi and 78.40% in Tan Lac). Mostly in the working age group, from 16-59 years (61.0 to 66.90%). Over 50% of patients with health insurance card. Over 70% of poor patients. Table 3.6. Referral patients from two hospitals to Hoa Binh provincial GH in 3 years (2006-2008) Index Kim Boi GH Tan Lac GH 2006 2007 2008 TB 2006 2007 2008 TB Total times of inpatient clinic 7124 9673 10777 9191 6359 6357 8859 7192 Total times of referral patients 816 946 1369 1044 232 371 572 392 Percentage (%) of times patients with transit 10.28 8.91 11.27 10.20 3.50 5.50 6.07 5.17 Compare rates (%) referral patients times (in comparison with the previous year) Reduced 1.37% (p>0.05) Increa sed 0.33% / year Increased 2.0% (p<0,001 Increase d 1.29% / year Increased 2.36% (p<0.001) Increased 0.57% (p<0.05) For Kim Boi GH: Rate of referral patient times up to Hoa Binh province GH in 2007 (10.28%) compared with 2006 (8.91) 1.37% decreased (p> 0.05) and 2008 (11 , 27%) compared with 2007 (8.91%) increased 2.36% (p <0.001). In average increased 2.42%/ year. For Tan Lac GH: The rate of referral patient times up to Hoa Binh province GH in 2007 (5.50%) compared with 2006 (3.50) increased 2.0% (p <0.001) and 2008 (6.07 %) compared with 2007 (5.50%) increased 0.57% (p <0.05). Increased average 1.29% / year. Table 3.7. Overline patients of the two hospitals Index Kim Boi GH Tan Lac GH 2006 2007 2008 TB 2006 2007 2008 TB Total inpatient times had clinic 7124 9673 1077 7 9191 6359 6357 8859 7192 Total times of p atient overline 331 510 633 491 276 326 506 369 Percentage (%) of patient times overline 4.65 5.27 5.55 5,07 4.16 4.88 5,40 4.88 Comparison of percentage of patient times overline (to the Increased 0.62% (p<0.05) Increased 0.45% /year Increased 0.72% (p<0.05) Increased 0.62% /year Increased Increased [...]... effectiveness of initial training model of technology transfer from province HO in order to improve the clinical capacity for district hospital 3.2.1 Building a model of technology transfer and training of provincial HO to promote the clinical capacity of district hospitals * To complete the direct line network to manage, administer and organize the training activities: Direct line network was set from the Health... Binh province GH 4.2.1 On the building of a training model of technology from province GH transfer to improve the medical capacity of district hospitals 4.2.1.1 Complete network of Direct lines One of the main tasks of the Directing line (DL) was the training activity for lower line Before implementing the research activities, General Plan Office of Hoa Binh province GH was in charge of referrals and. .. longer (4-5 years), to have the basis to evaluate the effectiveness, the impact of the model, from which lessons could be learned to expanded model to all of the district HOs of Hoa Binh province 2 Along with the provincial GH organization technology transfer training to the district GH The district GH need to actively recruit health staff (doctors, nurses) to meet payroll and plans to educate the postgraduate... results of training activities improving medical capacity for Tan Lac and Kim Boi district GH Primarily intervention of the model was the province GH organized training courses about technology transfer for the two health staff of Tan Lac and Kim Boi district GH as required to improve clinical capacity of each district GH The result of intervention activities on technology transfer and training of the model. .. surgery at both hospitals were enough under the distribution of technical expertise Except for equips supporting for essential newborn care at both hospitals were not available, or not synchronized, did not use 2 Construction and initial effectiveness evaluation the model of training clinics technology transfer for district hospitals - Models of technology transfer training for the two district hospitals. .. training With the consent of the Health Department of Hoa Binh province, a network of direct line of Hoa Binh province has been established Direct Line Network included all levels, from the Health Department to the communal health stations Network system of the Direct Line included: (1) Department of DL and (2) Branch DL in Hoa Binh province (3) SubCommittee DL in the district GH Department of DL of. .. Effectiveness of the model: the average duration of treatment (day)/ 1PT reduced from 0.23 to 0.30 day Total inpatient patients, total inpatient days, total number of tests, the total number of surgeries, tips increased from 1.03 to 2.86 times The referral rate decreased from 0.77 to 4.96% Overline rate decreased from 1.58 to 2.01% The rate of patients with different diagnosis of province GH decreased from. .. EIT = 60.54%) In the report on the health status of Vietnam Ministry of Health in 2007 showed that the quality of professional activities of the HO, in 2001, only 64% of patient referrals from provincial hospital or district hospital to central HO and only 51% of patients referrals from district hospitals to provincial hospitals were diagnosed correctly from the lower line - Neonatal care filed was markedly... evaluation of the model After intervention, initially some indicators of the professional activities of district GH have improved in the direction of better and more positive, in particular: - Average duration of treatment (day)/ 1PT fell from 0.23 to 0.3 day, other indicators such as total number of inpatient days, total number of tests, total surgeries, tips, total imaging tests increased from 1.03... (lowest) to 2.86 times (highest) - The patient referral: Average 2 years (2009-2010), total patient referrals from 2 distric GHs to Hoa Binh GH reduced from 2.0 to 1.04 times Patient referral rate of Tan Lac and Kim Boi GH decreased 4.96% Our results equivalent to the statement of Ha Nam Province GH, in two years (2008 and 2009) HO appointed 19 doctor times support and technology transfer for 6 district hospital . clinical capacity for district hospital 3.2.1. Building a model of technology transfer and training of provincial HO to promote the clinical capacity of district hospitals * To complete the direct. steps of the training cycle; The contents and training activities of technical transfer; indicators to assess the effects of model * The training technology transfer; Focusing on a number of. information and close to reality. * Technical training transfer activities: Hoa Binh Province GH had opened the training courses/ class for doctor, nursing, medical technicians of the two hospitals to