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					Catalan Health Institute
          (ICS)
Modernisation of the main public
 health institution of Catalonia
                                  Modernisation of the main
                             public health institution of Catalonia

                                                                   Improvement Actions
                                  ICS in figures

                                                                          Primary Care
           The ICS
                                                                         Hospital Care
           Organisation Chart
                                                                      Human Resources
           Health Centres
                                                                      Legal Assessment
           Health Care, teaching and research
                                                                Communication Office
           Human resources: distribution
                                                            Economy, Organisation and
           Budget 2004
                                                                              Finance
           Health-care activity (2004)
                                                                      Investments 2005
           Waiting lists (2004)
           Quality                                                    ICS challenges
           Pharmacy
                                                               Diagnosis Organisation
           Administration work
                                                             Background to the Reform
           Communication
                                                                       Driving change
           Infrastructures
                                                               Modernisation Strategy
                                                                        Law of the ICS

Institut
Català                                                                                   Pág. 2
                                    ICS in figures        Improvement Actions   ICS challenges

           The ICS is the main public institution in Catalonia. More than 35,000
           professionals carry out more than 50 million health-care interventions at its 8
           hospitals and 271 Health Centres.




                                                     Hiring




                          Other CatSalut providers



           The ICS reports to the Department of Health. Its budget is approved on a yearly
           basis by the Parliament of Catalonia.
           It works to standardise the contractual relationship between the CatSalut and the
           ICS and the relationship between the CatSalut and the other health-care centres of
           the XHUP (Public Hospital Network).


Institut
Català                                                                                       Pág. 3
                                       ICS in figures   Improvement Actions       ICS challenges

           ORGANISATIONAL CHART

                                              Managing Director

                                                                    Technical
                Human Resource Management
                                                                      Office
             Economic, Organisational and
                Financial Management                                Communication Office
                                                                      And User Service

               Infrastructure and Technical
                   Services Management                              Legal Assessment




                       Hospital Care Division                      Primary Care Division




                           8 hospital managements              8 Primary Care level managements



                                                                  30 Primary Care services




Institut
Català                                                                                            Pág. 4
                                   ICS in figures         Improvement Actions         ICS challenges

           HEALTH CENTRES: PRIMARY CARE

                                                               Care to 83% of the population of
                 8 Areas                                       Catalonia.

                               +    Pharmacy U.
                                                               5,488,092 of the assigned population
                                                               (equal to that of the Community of
             30 Primary Care                                   Madrid).
                 Services                                      9 call centers with a monthly average of
                                                               240,000 calls.
                               +    Laboratories
                                                               Action Plan in the Primary Care Centres
               464 Service                                     with the greatest demand, reducing excessive
                  Units                                        health pressure, and including 133
                                         8                     professionals and 62 new centres, in 2004.


                                                                       Service units
           Primary Care areas

                                        1. Lleida
                                        2. Tarragona- Terres
                                           de l’Ebre
                                        3. The city of
                                           Barcelona
                                        4. Girona
                                        5. Costa de Ponent
                                        6. Barcelonès nord i
                                           Maresme
                                        7. Centre


Institut
Català                                                                                                Pág. 5
                                  ICS in figures              Improvement Actions                    ICS challenges

           HEALTH CENTRES: HOSPITAL CARE


                                                                                                    8 Hospitals




                                                                                              32% of the beds of
                                                                                             the Public Hospital
                                                                                                Network (XHUP)




                                                                                         Offices
                                                                       Operating
                                                               Beds                       query
                                                                        theatres
                                                                                       Outpatient
                          County H. H. Viladecans                104               4          23
                       Reference H. H. Verge de la Cinta         222               6          54
                       Reference H. H. U. Arnau de Vilanova      432           11             53
                       Reference H. H. U.   Joan XXIII           325               8          61
                       Reference H. H. U. Dr. Josep Trueta       372           11             50
                     High-technology H. U. Germans Trias i       613           15             63
                                  H. Pujol
                     High-technology H. U. Bellvitge             792           27            119
                                  H.
                     High-technology H. U. Vall d'Hebron       1,265           44            213
                                 H.    TOTAL                   4,125         126             636




Institut
Català                                                                                                            Pág. 6
                                           ICS in figures             Improvement Actions         ICS challenges

               HEALTH CARE, TEACHING AND RESEARCH

               The ICS is a pioneer in its three basic lines of activity: Health Care, Research and
               Teaching.


               It is the main health-care supplier of the CatSalut, and its centres, renowned for
               their quality, are among the most scientifically productive in Spain. It provides a
               large part of the medical and nursing graduates trained in Catalonia.



                        CARE                              RESEARCH                             TEACHING
              It has 80% of the primary          It provides more than 40% of         Undergraduate and post-
               care centres.                       the scientific output of              Graduate training supplies 56%
                                                   Catalonia.                            of the medicine graduates and
              It provides 32% of total
                                                  Its centres are among the most        66% of the specialists trained
               hospitalisation beds plus 50%
                                                   productive in Spain (documents        in Catalonia.
               of tertiary beds.
                                                   can be cited):                       There are 39 professors of
              It is the main transplant
                                                       no. 2 H. Vall de Hebron.         medicine.
               performer (2004):
                                                       no. 3 H. Bellvitge.             More than 1,500 MIR
                   100% Lung.
                                                       no. 13 H. Trias i Pujol.         (residents) are trained in ICS
                   46% Kidney.
                                                  Its research publications have        centres.
                   27% Heart.
                                                   great scientific value (total        More than 4,300 under-
                   62% Liver.                     impact factor of 2.8 for 2004).       graduates:
                                                  More than 303 research projects           2,300 in medicine.
                                                   (2004).
                                                                                             2,000 in nursing.




Institut
Català                                                                                                             Pág. 7
                                     ICS in figures            Improvement Actions      ICS challenges

           REFERENCE SERVICES IN THE HOSPITAL CENTRES

           • Hospital Universitari Germans Trias i Pujol AIDS patient care Unit.

           • Hospital Universitari Vall de Hebron         Burns Unit and Lung Transplant Unit:
             both are reference hospitals for the whole of Catalonia.

           • Hospital Universitari Vall de Hebron              Digestive Apparatus Service: Crohn's
             chronic digestive disease that affects 20 out of every 100,000 citizens of
             Catalonia.

           • Hospital     Universitari Vall de Hebron         Fetal Surgery    and Paediatric Surgery
             Unit.

           • Hospital     Universitari   Bellvitge        Heart   Surgery   with    post-heart   surgery
             reanimation unit.

           • Hospital Universitari Bellvitge        Anorexia and Bulimia Unit.

           • Hospital Universitari Bellvitge        Liver Transplant Programme. Groundbreaking
             in Spain since    1984. Facilities:

                                     •   20 morning operating theatres

                                     •   4 afternoon operating theatres

                                     •   One-day hospitalisation unit (Major Ambulatory Surgery).



Institut
Català                                                                                               Pág. 8
                                               ICS in figures            Improvement Actions                  ICS challenges

            HEALTH-CARE OFFER
                               HOSPITAL BEDS                                                   PRIMARY CARE CENTRES

                                                                 300
           70,0%
                                                  64,7%                269

           60,0%                                                 250



           50,0%
                                                                 200


           40,0%
                                   32,8%                         150

           30,0%
                                                                 100
           20,0%
                                                                                 60

                                                                 50                                              40
           10,0%                                                                                   35                    32
                      2,5%                                                                15             15                       8

           0,0%                                                    0
                   Basic General   Reference   High technology


                                                                             EAP: Primary Care Teams.
                                                                             Other services (emergencies, occupational health)
                                                                             Rehabilitation.
                                                                             PASSIR: Sexual and Reproductive Health Care.
                                                                             PADES: Home Care Programme, Support Teams.
                                                                             Other specialities.
                                                                             SPDI: Imaging Diagnosis Services.
                                                                             Laboratories.



Institut
Català                                                                                                                           Pág. 9
                                          ICS in figures             Improvement Actions            ICS challenges

           PROFESSIONAL TEAM
                           The ICS has more than 35,000 professionals
             WORK FORCE BY TYPE OF CONTRACT 2004                           WORK FORCE BY CARE AREA 2004



                                    MIR / LLIR                           Corporate C
                                           5% Civil servants                2%
                                                        2%
            Non health
                  25%                                   Work
                                                           0%




                                                    Doctors
                                                        25%



                                                                         Primary C                        Hospital care
                                                                           52%                               46%
                 Sanitary
                     43%
            MIR: Interns

                           Lleida                                1.115      H. Viladecans                           432
                           Girona                                1.498      H. Verge de la Cinta                    683
                           Tarragona-Terres de l'Ebre            1.747      H. U. Arnau de Vilanova               1.247
                           Barcelonès Nord i Maresme             2.147      H. U. Joan XXIII                      1.159
                           Costa de Ponent                       3.856      H. U. Dr.Josep Trueta                 1.263
                                                                            H. U. Germans Trias i Pujol           2.039
                           Centre                                3.567
                                                                            H. U. Bellvitge                       3.289
                           City of Barcelona                     4.643
                                                                            H. U. Vall d'Hebron                   6.252
                           Total                                18.573      Total                               16.364

Institut
Català                                                                                                             Pág. 10
                                  ICS in figures        Improvement Actions    ICS challenges

            MODERN MANAGEMENT OF HUMAN RESOURCES
            PROFESSIONAL CAREER:
                Retributive model for medical personnel, nursing and other voluntary access
                 diploma holders.
                Instruments for identifying and stimulating professional careers      in line with
                 the objectives of the ICS.
                Five-tier structure according to years of employment and professional merits,
                 measured through health-care activity, training, commitment, teaching and
                 research.
                                                         Hospitals   Primary
                Results 2004:          Doctors             758        829     1.587
                                        DUI (Nursing)     2.261      1.904     4.165
                                                          3.019      2.733



            MANAGEMENT BY OBJECTIVES:
                Variable productivity bonus for accomplishing pre-established goals measured
                 using standard indicators.
                The professional's individual goals are linked to the organisation            they
                 guarantee organisational consistency.

                   • Median accomplishment of 80.9% in primary care (3,431 doctors).
                   • Median accomplishment of 79.0% in hospitals (2,013 doctors).




Institut
Català                                                                                      Pág. 11
                                            ICS in figures                Improvement Actions                 ICS challenges

            BUDGET 2004
                                                                       53.3




            Total ICS                                                                 863.7
                                                                                              Million €
                 2,022                       1,105.9

                                                                                                    Primary Care
                                                                                                    Hospital Care
           Data in million €
                                                                                                    Corporate Centre


                    HOSPITAL CARE: Distribution by chapters
                                                                                     PRIMARY CARE: Distribution by chapters
                                              0.03%
               100%                            1.4%                                                                 0.04%
                                                                              100%                                  0.8%
                90%
                                                                               90%                                  14.7%

                80%
                                              40.4%                            80%
                70%
                                                                               70%
                                                          Chap. VIII
                60%
                                                          Chap. VI             60%
                50%                                       Chap. II
                                                                               50%
                                                          Chap. I
                40%                                                                                                 84.4%
                                                                               40%

                30%                           58.1%                            30%

                20%                                                            20%

                10%                                                            10%

                  0%                                                            0%
Institut                             1                                                                    1

Català                                                                                                                     Pág. 12
                                ICS in figures             Improvement Actions            ICS challenges

           HEALTH-CARE ACTIVITY
                HOSPITAL CARE                                    Hospital Care 2004                    %v2003
                                          Conventional Discharges                        174,270         2.0%
                                          CMA Discharges                                   32,814        3.0%
                                        Total Discharges                                207,084          2.2%
                                           Scheduled surgery                               51,105        1.6%
                                           Emergency Surgery                               21,720        2.7%
                                        Total surgical activity                         105,639          2.2%
                                        Emergencies                                     805,623         -0.6%
                                        Pressure emergencies                               60.90%       0.00%
                                           First visits                                  800,636         4.2%
                                           Index of repetition                              3.09       -1.60%
                                        Total Outpatient                               2,111,700         2.9%
                                        Day Hospital                                    154,855         10.2%
                                        Hosp. Diagnostic tests                          134,360




                                                                 Primary Care 2004                     %v2003
                PRIMARY CARE
                                           Family Medicine Visit                       18,477,209        9.1%
                                           Paediatric Visit                             3,489,335        7.5%
                                           Nursing visit                               10,613,775        1.2%
                                        Total visits EAP                              32,854,132         6.2%
                                            Home Family Medicine                         248,980        -45.6%
                                            Home Paediatrics                                4,686       -71.6%
                                            Home Nursing                                 226,539        -60.4%
                                        Total visits home EAP                            480,205       -54.1%
                                        Total visits EAP                              36,586,567
                                         Specialised Visits extrahosp.                 1,006,525
                                           Lab tests ICS centres                       17,724,102        6.8%
                                            Radio diagnostic explorations               1,396,359        -2.3%
                                        Diagnostic explorations                       19,120,461

                                                                      EAP: Primary Care Team.
                                                                      CMA: Major Ambulatory Surgery.
Institut
Català                                                                                                    Pág. 13
                                      ICS in figures      Improvement Actions      ICS challenges

           WAITING LISTS
                         HOSPITAL CARE

           Surgery waiting list for the 14 procedures
           monitored by the CatSalut.
                                                        n (2004)   % variation vs 2003
                       Patients on waiting list          13,720         -10.8%
                       Surgery performed on the
                       waiting list                      28,216          -0.6%

                       Resolution time (months)           5.8           -10.8%




                         PRIMARY CARE


           Delay, defined as 20% of free spaces by
           specialist agenda


                                                        n (2004)    % variation vs 2003
                      Patients on waiting list           148,683          -0.6%
                      Delay (days)                         44             -5.0%




Institut
Català                                                                                      Pág. 14
                                                                   ICS in figures                   Improvement Actions                    ICS challenges

           HIGH COST PROCEDURES




                                                                                                       8,030
                                                                                               7,364
                                                   9,000                                                                                          2003

                                                                                                                                                  2004




                  Number of high-cost procedures
                                                   7,500




                                                                                     3,877
                                                   6,000




                                                                             3,753
                                                                    3,171
                                                           2,971
                                                   4,500

                                                   3,000




                                                                                                                     524


                                                                                                                           614




                                                                                                                                                316
                                                                                                                                         267
                                                   1,500

                                                    -
                                                              Heart          Orthopaedic       Haemodynamic            Vascular   Others (Implants
                                                             surgery           surgery                                 surgery     cochlear, LCR
                                                                                                                                        valves,
                                                                                                                                  Neurotransmitters)




                                                                                                               Difference 2004 vs 2003
                                                                                                                                                 Increase
                                                                            2003             2004                N                %            expense 2004

               Heart surgery                                                 2,971            3,171               200              6.7%   781,990 €
               Orthopaedic surgery                                           3,753            3,877               124              3.3%   392,523 €
               Haemodynamics                                                 7,364            8,030               666              9.0% 1,029,370 €
               Vascular Surgery                                                524              614                90             17.2%   231,399 €
               Others (Implants cochlear, LCR
               valves Neurotransmitters)                                      267              316                   49           18.4%          280,240 €

                                                                            14,879           16,008             1,129                 10% 2,715,522 €

Institut
Català                                                                                                                                                        Pág. 15
                                             ICS in figures              Improvement Actions             ICS challenges

            EFFICIENCY OF HEALTH-CARE ACTIVITY

                                                HOSPITAL DISCHARGES 1996-2004
                       176,704

                       172,688
                                                                                  6.5%
                       168,672

                       164,656

                       160,640

                       156,624

                       152,608

                       148,592
                                        96       97    98           99      00         03         04

                PERCENTAGE READMISSIONS 1996-2004                                  GROSS MEAN STAY 1996-2004

                                                                    10
           12   11.1
                                                                          8.9               8.8
           10          9.4                                           9           8.7              8.7   8.6
                                                                                                              8.38          -8.4%
                                                                                                                     8.07
           8
                                                                     8




                                                             days
                                                                                                                             7.39
           6
                                 4.61          4.3                   7
           4                                          3.08

           2                                                         6


           0                                                         5
                96      00       02            03      04                 96     97         98    99    00    02     03      04

Institut
Català                                                                                                                 Pág. 16
                                                      ICS in figures             Improvement Actions            ICS challenges

           CASE MIX: CASE MIX
                                           The 10 most frequent GRD accumulate 20.4% of the total of the
                                                              of ICS hospital discharges in 2004

                                              GRD                                   Disch.    % Disch    % accum. disch. Relative weight
           373 Vaginal partum without complication diagnosis                        9494       4.7%            4.65%         0.393
           039 Crystalline pg with ¢ without vitrectomy                             9103       4.5%            9.11%         0.594
           088 Chronic obstructive pulmonary disease                                3832       1.9%           10.99%         0.903
           209 Pq lower extremity, reinsertions/replace. major articul.             3663       1.8%           12.78%         2.078
           127 Heart failure and shock                                              3198       1.6%           14.35%         1.004
           359 Pq uterus/adnexa, non-malign, w/c                                    2767       1.4%           15.70%         0.835
           014 Intracranial haemorrhage and ictus with infarct                      2737       1.3%           17.04%         1.294
           187 Tooth extractions/repairs                                            2597       1.3%           18.32%         0.867
           035 Another nervous system disorders w/c                                 2135       1.0%           19.36%         0.639
           371 Caesarean section w/c                                                2131       1.0%           20.41%         0.675

             Total disch.                                                         204.132                                    1.183



                                      Rate of standard operation                                      0.958




                                      % replacement of major                                          63.9%
                                      ambulatory surgery


                                     % of emergency readmissions in the                               1.2 %
                                     same GRD (in less than 30 days)




Institut
Català                                                                                                                         Pág. 17
                                        ICS in figures        Improvement Actions        ICS challenges

           CONTROL OF PHARMACEUTICAL EXPENDITURE


            13
                                                                            12.15 12.24
            12

            11           10.69
                 10.57
                                                              9.89
            10                                                       9.54

             9

                                                7.93
             8                   7.52   7.49

             7
                                                                                               6.4

             6                                         5.64

             5                                                                                       4.6

             4
                     1999           2000          2001           2002            2003            2004


                                                                            % Increase expenditure Catalonia
                                                                            % Increase expenditure Spain




Institut
Català                                                                                                  Pág. 18
                                                                                         ICS in figures                                          Improvement Actions                                                             ICS challenges

            PHARMACEUTICAL EXPENDITURE BY AA (AUTONOMOUS COMMUNITIES)

           12



           10



           8

                                                             6.75%
           6

                                  4.6%
           4



           2



           0




                                                                                                                                                                                                     Extremadura
                                                                                                                                                               Castilla- La Mancha




                                                                                                                                                                                                                                                Ceuta
                                                                                                                                                                                                                   Madrid

                                                                                                                                                                                                                            Murcia
                                  Catalán




                                                                                                                                                                                                                                                        Melilla
                                                                                                                                                                                                                                     La Rioja
                                                                                                                                                 Cantabria
                                                              S. Gallego




                                                                                                   S. Canario




                                                                                                                                                                                     Castilla-León
                                                                           S. Navarrés




                                                                                                                                      Baleares
                                                                                                                  Aragón
                                                                                         S.Vasco
                                             S. Valenciano




                                                                                                                           Asturias
                     S. Andaluz




                12
                                            10.96%                                                     10.16% (*)
                10

                8                                                                                               4.73%                                        Catalonia is 2.15 per cent below the
                                                                                                                                                             national average (2004)
                6

                4
                                                                                                                                                             The ICS has generated savings of 63.5
                                                                                                                                                             million € corresponding to the Order of
                                                                                                                5.43%
                2                                                                                                                                            Reference Prices.
                                                                                                                                                             Real savings have been higher than
                0                                                                                                                                            expected.
                                                02/03                                                            03/04

                        (*) Theoretical growth without the effect of
                        the Reference Prices

Institut
Català                                                                                                                                                                                                                                                  Pág. 19
                                     ICS in figures        Improvement Actions        ICS challenges

           ADMINISTRATIVE PROCEDURES


                        HUMAN RESOURCE AREA



                                                                   196,000 formalities
                   Personnel management (licences, authorisation,...)
                  Area of development (MBO, claims,...)               50,000 formalities

                  Occupational hazards (queries, planning,...)        30,000 formalities


                                                                    265,000 formalities

                       LEGAL ASSESSMENT


              Legal defence, reports, hiring and contracting, agreements...

                                                                     8,000 formalities


                         SHORT-TERM CONTRACTS

              Recorded in the primary care division in the centres

                                                                       36,000 contracts

                                                                                 MBO: Management by objectives.
Institut
Català                                                                                               Pág. 20
                                           ICS in figures           Improvement Actions    ICS challenges

            MASS MEDIA



                                    MEDIA IMPACT 2004

           6.000
                                                         5.317

           5.000

                                                                              ASSESSMENT OF IMPACT 2004
           4.000


           3.000                                                             Negative
                                                                              15%

           2.000

                                            1.079
           1.000         763


            -
                        Corporate         Primary Care   Hospital
                         Centre                            Care


                   The ICS appeared 7,159 times in the mass
                                 media in 2004                                                            Positive
                                                                                                           85%




Institut
Català                                                                                                Pág. 21
                                                          ICS in figures         Improvement Actions      ICS challenges

                 INFRASTRUCTURES
                           The lack of investment has led to a major decapitalisation in the ICS's
                            infrastructure.
                           Over the last few years a major investment deficit has accumulated: the minimal
                            annual investment need was 63 million € (calculated from 4% of the updated
                            construction value), while average investment between 1991 and 2003 was 41 million
                            €.
                                                                                                        Period 2005-2019
                                                                                                   Equipment             326
                                                                                                   Installations         395
                           70                                                                      Work                  881
                                                                                                   Total               1.602
                           60
                                                                                                           Annual average
                           50                                                                      Equipment               22
                                                                                                   Installations           26
                                                                                                   Work                    59
                           40
               Million €




                                                                                                   Total                  107

                           30                                                                             In million euros


                           20

                           10

                           0
                                1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003


                                          Interventions      Need inves       Mean inves


                          The calculation of needs to recover from the historic decapitalisation for the 2005-
                           2019 period stands at an annual investment rate of 107 million €.

Institut
Català                                                                                                                       Pág. 22
                                  ICS in figures         Improvement Actions       ICS challenges

           USER SATISFACTION (Primary Care)

               Improvement in overall satisfaction with the Primary Care Teams of the ICS.
                Score of 7,84 out of 10 in 2004 (outperforming the 7.51 of 2003).
               Three (3) out of every 4 Catalans perceived care as excellent, good or very
                good.
               88,6% of the population has been seen a health professional at least once this
                year.
               The rating of the feeling of being in good hands was 8.06.
               Satisfaction with medical care is 8.19, with care for disease standing at 8.25
                and satisfaction with installations at 8.25.
               92% of users would recommend their centre to friends.
                                  Does your centre solve your normal health
                                           (disease) problems?


                                          2.1%           5.2%
                                                                7.9%




                                                                   25.98%
                                  58.8%




                          Never     Rarely       Often      Alm. always        Always


Institut
Català                                                                                      Pág. 23
                                      ICS in figures       Improvement Actions       ICS challenges

           PRIMARY CARE DIVISION

                                                          Improvement Actions
           •   Accessibility:

                  •   Opening of new services that will facilitate access by citizens to the
                      system:

                                • Telemedicine services: Primary Care Area of the Pyrenees.
                                • Care Services to Travellers in Osona and El Baix Llobregat.
                                • Rehabilitation service in Viladecans and Tarragona.
                                • Health Programme and the School: provide health care in schools.
                  •   Improved ongoing and emergency care:

                                •   Creation of 5 Primary Care Emergency Centres: Cornellà, Matarò,
                                    Manso, Cerdanyola and Lleida.
                                •   Improvement of emergency services: CAP Sant Félix, CAP Guell,
                                    Alta Ribagorça, Terres de l’Ebre and Hospitalet.
                                •   Pilot test: emergency home care vehicles.
                                •   Coordination devices with reference hospitals.
                                •   New equipment for ongoing care centres.

                  • Call centres: Streamlining of resources through a single telephone number
                      for scheduling all visits.


Institut
Català                                                                                        Pág. 24
                                      ICS in figures    Improvement Actions    ICS challenges

           PRIMARY CARE DIVISION


           •   Health-care quality:

                  •   Increase problem-solving capacity of health centres:

                        •   Give all health centres: spirometers and pulse meters,
                            defibrillators, Doppler and non-mydriatic cameras.
                        •   Extension of OAT control in primary CARE.

                  •   Training:

                        •   By e-learning: More than 8,000 workers and a decentralised training
                            offer.
                        •   Management Training.

                  •   Increased diagnostic capacity:

                        •   New radiology, CT and ultrasound equipment: Osona, Hospitalet,
                            Vilanova i la Geltrú, Gavà, Nou Barris, Granollers and CAP Manso.

           •   Comfort and safety:

                  •   Air-conditioning of health centres:

                        •   All health centres completely air-conditioned.

                  •   Environmental audits:

                        •   European environmental certification (EMAS).


Institut
Català                                                                                    Pág. 25
                                   ICS in figures          Improvement Actions   ICS challenges

           HOSPITAL CARE DIVISION


           •   Accessibility:

                  •   Project for the improvement of emergency care:

                        •   Professionalisation of the classification and selection of
                            emergencies.
                        •   More emergency health-care professionals: 32 new arrivals.
                        •   Project for computerised patient reception and electronic medicine
                            prescription.
                        •   PISA Project: Prevention of emergency department crowding in the
                            winter.

                  •   Cancer care programme:

                        •   Implementation of quick-diagnosis circuits.
                        •   Daytime cancer consultation.
                        •   New oncology service and linear accelerator in H.Arnau de Vilanova.

                  •   Waiting lists:

                        • New integrated management plans.
                        • Improved information systems and circuits.
                        • Project to reduce knee replacement and heart     surgery waiting time.



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               HOSPITAL CARE DIVISION

           •    Health-care quality:

                   •   Replanning of services:

                         •   Critical and semi critical hospital patients: Germans Trias i Pujol,
                             Josep Trueta, Viladecans and Arnau de Vilanova.
                         • Gynaecology, obstetrics and paediatric Hospitals: Arnau de Vilanova and
                             Josep Trueta.

                   •   Promote alternatives to hospitalisation:

                         •   Major Ambulatory Surgery.
                         •   Day Hospital.

                   •   Unit for integrated patient support throughout the health-care process.

                   •   Collaboration between hospitals:

                         •   Hospital Vall de Hebron/Arnau de Vilanova: oncology and neonatology.
                         •   Hospital Josep Trueta/Germans Trias i Pujol: heart surgery.

                   •   Genetic and molecular medicine service (H. Vall de Hebron) and acute
                       psychiatry care in collaboration with CAP San Rafael.

                   •   High-cost and highly-complex procedures    and emergency conditions  1 million
                       € earmarked to increase coronary stents in the following Hospitals: Germans
                       Trias i Pujol, Bellvitge and Vall de Hebron.
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            HUMAN RESOURCE MANAGEMENT


           • Implementation of the “Framework Statute” Law of statutory personnel:
                     • Establishment of maximum number of working days and planning of
                       work time.

                     • Determination of professional categories and their functional
                       content.

                     • Reform of the primary care contingency staff from 2.5 to 6
                       hours, affecting:
                            •     460 GPs.
                            •     180 Nursing Staff.
                            •     120 Paediatricians.
                            •     45 Midwives.




                     • Social action funds (additional non-economic resource funds to
                       improve the working conditions of statutory personnel:
                       nurseries, food)

                     • New regulation of permission and licences adapted to the
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Català                 Framework Statute (for studying, marriage, leaves of            Pág. 28
                                     ICS in figures     Improvement Actions    ICS challenges

           HUMAN RESOURCE MANAGEMENT


           • Completion of the implementation of the Agreement on working conditions of
              29 October, 2002; improved development of MBO (management by Objectives)
              and of professional career process:

                      •   2,734 professionals may be included in the professional career levels I,
                          II, III.

                      •   4,138 professionals may be included in professional career level IV.

           • Undertake recruitment processes to stabilise the workforce of the ICS and
              implement policies that promote the employment of workers with
              disabilities.

           • Design and implementation of a human resource information system for the
              whole ICS, complementing the existing personnel management system.

           • Implement an occupational hazard prevention plan and continue with work
              already done in the area of psychosocial risk (physical and psychic
              aggressions, mobbing).


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           ECONOMIC AND FINANCIAL MANAGEMENT


           • Improvement of Information systems, expanding the SAP project to the
              economic and financial levels of management and planning. The medium-
              term objective is to implement the SAP project in the management of ICS
              hospital patients.

           • Rendering of logistics and warehousing services in primary care via a
              single company: Logaritme. The supply, storage and distribution of
              consumable material requires an ideal location, with modern,
              computerised and automated structures to leverage efficiency.

           • Single Call Centre for all the citizens of Catalonia.
           • Increase the rendering of the aggregated purchase of intermediate
              products (complementary tests). Move towards the ICS centres taking over
              all intermediate products.

                      • 86.9% of the remaining tests will be allocated by calls for tenders,
                          generating savings of 3.6%.

                      •   13.5% of tests undertaken are expected to be taken over by ICS centres.
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           INFRASTRUCTURE AND TECHNICAL SERVICES MANAGEMENT

                             301 Primary Care Centers: 473.318 m 2
                                   8 hospitals: 593.727 m2


           • Implementation of solar energy for the sanitary hot water network (ACS).
           • Implementation of phase II of air-conditioning in primary centres.
           • Environmental management project (EMAS) in three ICS hospitals and in 30
              Primary Care Centres (CAP).

           • Implementation of the first phase of the electro medical equipment plan.
           • Preparation of guides for responsibility in destruction of confidential
              information and protocols to analyse the critical areas of hospitals.

           • Promote global and homogeneous inventorying of all electro medical
              equipment in ICS centres to:

                       •   Ascertain the value of its assets

                       •   Ascertain the average service life of the equipment.

                       •   Pre-empt electro medical equipment replacement needs.
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           LEGAL ASSESSMENT


           • Maintain the levels of activity recorded in 2004 and optimise resources
              and results

           • Approval of the Law of the ICS and the decrees submitted in the course
              of 2004:
                        • Decree for the Modernisation of the ICS (along with HR).
                        • Decree regulating organisations that participate in hospital centres.
                        • Decree on prevention of and action against aggressions.




           • Develop the Insurance Brokerage function for the asset liability
              policy.

           • Extension of Legal Assessment in Tarragona and Lleida (new offices).
           • Install a new “on-line” data base of Legal Assessment in Girona,
              Tarragona and Lleida: Achieve the paperless office.

           • Reorganisation of Legal Assessment: prioritising by-topic/subject
              specialisation of lawyers.
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             COMMUNICATION OFFICE
           • Corporate web of the ICS
                       • Develop the scheduling of nursing/infirmary appointments.

                       • Sexual and reproductive health Web in the framework of the Health
                         and School programme.
                       • Management of the implementation project.



           • Intranet Portal
                       • Management of the implementation project

                       • Development of instruments of participation and debate: Forum,
                         weblog,    videoconference.



           • Harmonisation of contents, webs and publications of the ICS and Health.
              Hosting of webs in the domain of the Autonomous Government of Catalonia.

           • Promote digital publications targeting professionals and increase the
              number of publications, on paper and on-line, for users.



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           INVESTMENTS 2005
           Hospital care: 77 million €*           85 Works and 38 projects

           Work:                                                 Projects:
           most relevant                                         most relevant

            • H. Bellvitge: Phase I-II new building.              • H. Vall d’Hebron: Emergencies (General),
            • H. Vall d’Hebron: Surgery block general area and    paediatric ICU (Maternity/children’s) and
              traumatology area..                                 Emergencies (Traumatology H).
            • H. Germans Tries i Pujol: Research and teaching     • H. Germans Tries i Pujol: Emergencies and
              laboratory.                                         reform of Hospitalisation floors.
            • H. Josep Trueta: New safety/security systems.       • H. Josep Trueta: New ambulatory building.
            • H. Verge de la Cinta: ICU and sterilisation         • H. Arnau de Vilanova: Reform emergencies.
            • H. Joan XXIII: extension of the CT and              • H. Joan XXIII: Reform of the emergency
              densitometry.                                       service and the 3rd hospitalisation floor.
            • H. Arnau de Vilanova: Linear accelerator and        • H. Verge de la Cinta: Surgery block and 1st
              replacement of CT and its area.                     hospitalisation floor.
            • H. Viladecans: development of the car park          • H. Viladecans: new surgery block.


           Primary care: 48 million €*  71 Works and 124 projects

            Work:                                                   Projects:
            most relevant                                           most relevant

             • CAP Martorell: reform.                                 • CAP Eixample de Lleida: extension.
             • CAP Sant Feliu de Guíxols: reform.                     •   CAP   Bages: extension.
             • CAP Mollerussa: extension.                             •   CAP   Deltebre: extension.
             • CAP Sant Pere y Sant Pau: extension.                   •   CAP   Vilanova del Vallés: new centre.
             • CAP Montcada y Reixac-2:new centre.                    •   CAP   Sant Andreu: new floors.
             • Centre de Diagnòstic Ràpid de l‘Hospitalet.            •   CAP   Sant Martí: reform.
             • CAP Rambla de Sabadell: new centre.                    •   CAP   Manresa IV: new centre.
             • CAP Alcanar: new centre.                               •   CAP   Riudarenes: new centre.
             • CAP Santa Perpetua de la Mogoda:                       •   CAP   Just Oliveras: reform.
             extension.


             * Total sources of funding
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Català                                                                                                       Pág. 34
                           ICS in figures   Improvement Actions   ICS challenges




           The process of modernisation of the
                Institut Català de la Salut


           The Law of modernisation of the ICS will make it possible to
           provide new health-care and organisational solutions geared
            towards increasing the degree of efficiency of the public
              health system of Catalonia and to bringing in business
            management criteria based on the removal of red tape, more
               flexible economic management and decentralisation in
                    decision-making at centres and in services .




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               SOME BRIEF BACKGROUND

                1981  Transfer of Health powers (health and social centres and services) to

                 Catalonia.

                1981-1983  Beginning of the management and implementation of the health map

                 of Catalonia: accreditation of centres and first order of agreements.

                1983  The basis for the model was established: creation of the ICS, managing

                 organisation of the health services of the Social Security.

                1983-1989  The Public Hospital Network was created, the reform of primary

                 care was undertaken and hospital care was replanned and management

                 decentralised.

                1989-1991  Beginning of the separation of the funding and provision with the

                 creation of the General Board of Economic Resources of the Social Security

                 (DGRESS).

                1991  Approval of the LOSC

Institut        2005  Process of Modernisation of the Law of the ICS.
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           REASONS FOR CHANGE
            1.    Institutional normalisation: The ICS must find its own space within the
                  institutional reality of Catalonia, expanding the vision of what the managing
                  organisation of the Social Security is.
            2.    Governing Board: creation of the governing board as a management organ of the ICS
                  and in charge of setting the major goals and accountability..
            3.    New human resource model.
            4.    New economic operation model: own treasury, permanent instead of preliminary
                  financial control, own assets and securing of credits within the limits
                  established by the Autonomous Government of Catalonia.



           PRINCIPLES: INDEPENDENT MANAGEMENT AND DECENTRALISATION

           5.    New organisational legal solution with a view to improving efficiency.
           6.    Incorporation of business criteria.

           CREATION OF A PUBLIC COMPANY

           7.    Simple law to make it easier to understand.
           8.    ICS as an organisation with its own legal status and reporting to the Autonomous
                 Government of Catalonia.
           9.    Basis for developing future company statutes.


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                                     ICS in figures       Improvement Actions     ICS para el ICS
                                                                                Retos challenges

           MAIN ISSUES SOLVED

           1.     Gives major powers and responsibility to the governing board to set targets and
                  approve the programme.
           2.     Global organisational reengineering: redefinition of the role of the corporate
                  centre, simplification of the organisation and modernisation of processes and
                  systems.
           3.     It retains the critical powers needed to govern the ICS, develop the backbone
                  policies of the Department of Health and its portfolio, as well as the budget
                  strategy.
           4.     It retains the essential powers: As an economic and human resource model,
                  shared services and general framework to prepare the regulations pertaining to
                  how its management units are structured and operate.


           EXAMPLES OF IMPROVEMENT
                All new investments (excluding replacement) ultimately depend on the Servei Català
                de la Salut with execution via GISA or through other channels.
                     The execution of the ICS's infrastructure budgets will be approved by the
                     governing board.

                At the moment, the Autonomous Government of Catalonia invoices third parties (other
                organisations, people or companies).

                    Invoicing to third parties will depend on the ICS, thus generating greater
                    income.
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Català                                                                                       Pág. 38

				
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