Study On Improvement And Development Strategy For The Quality Of Community Health Care In Shanghai City

Background"Primary Health Care, Now More Than Ever" was pointed out by World Health Organization (WHO) in the World Health Report 2008. The principles of "People-oriented", "patient-centered" and "community-based" have been advocated in Community oriented Health care Service (also named Community Health Service, CHS), which was integrated Primary Health Care (PHC) and General Practice (GP). CHS holds essential clinical services and public health service as a basic level of medical service system and public health system. The development of CHS and improvement of quality of care are guarantee of health for all, effective control for the growth of medical expenses and requirement of maintaining health. In recent years, more and more attention on patients' participation in quality management of CHS has been paid by health planner and administrators. Therefore, in order to develop and improve the people-oriented and patient-centered CHS, it is necessary to make an evaluation by using the information of patients' experience for quality of care so as to come up with practical measures for improvement. However, faced with the expansion of clients in health service and increasing demands for services, how to work effectively and improve significantly the quality of care is critical to the improvement of trust and satisfaction for CHS among residents and sustainable development in community health workers of the General Practitioner Service Team (GPST). Few researches on comprehensive analysis of each aspects of community health center as microsystem and on latent influence factor of low satisfaction was presented in the recent literature. In this study, focusing on the above issues and improvement of service quality, successful experiences and weakness will be summarized for the actual CHS practice so as to provide the scientific evidence of sustainable development of community health services.Goal and ObjectivesGoal: Through microsystem analysis framework of primary care practice, to analyze the status of patient, provider, process and patterns in CHS, to sum up useful experience and effective way and to provide evidence for rational planning service and the continuous improvement of quality of care in order to promote the provision of more and more Good primary health care for more community residents. Objectives:●To describe the service content and strategies in community health center●To describe the process and pattern in the community health center●To explore strengths and problems on quality of care for CHS, find the difference among CHS institutions including health service centers and health stations that are affiliated with community health centers as a site in every subdistrict, and analyze advantageous factors and obstacles by exerting microsystem frameworkResearch ObjectsPatients, community health workers and key persons such as heads of GPST, division of prevention and care, and community health center selected in all the community health centers and health stations from a region in Shanghai city were investigated.Research Content1. Patient: satisfaction degree for the process of CHS; needs assessment and utilization for CHS2. Provider: status of human resources and job satisfaction in CHS; medical personnel's training status and needs assessment on training; demands and assessment for job among community health workers; SWOT analysis for GPST3. Process and pattern: process; pattern and management features; the SWOT analysis for CHS and development strategiesMethodsIn this study, the case study design was conducted with application of combining quantitative and qualitative methods, namely mixed methods. Firstly, the survey on both satisfaction degree for CHS among patients and job satisfacition among medical staff in community health centers by questionnaire were conducted in the quantitative study. Followed by reference to the results of quantitative research, qualitative research was carried out, including observation for process, in-depth interviews with patients and medical personnel and focus group discussions among GPSTs and key persons. Data were analyzed by descriptive and analytical methods. The main analysis methods included descriptive analysis, uni-variable analysis, latent class analysis, structural equation model analysis, qualitative analysis, SWOT analysis.ResultsThe findings of four principal parts except to first section on general description of conditions in the region and CHS institutions surveyed were presented as following:Section II: The Analysis of Patients on CHS 1. The analysis of satisfaction degree for the process of CHS among patientsData was obtained from a cross-sectional survey on clients' satisfaction for CHS. This study focused on outpatients of 11 community health centers (N=l,623). 70.3% subjects were willing to choose the community health center for treatment. 56.6% of these subjects stated "convenience" as the primary factor. Total satisfaction was 63.8%. A four-class categorization was exhibited the best fit with the data through latent class analysis. Based on class characteristics, the classes were named "overall satisfaction"(36.27%), which mean subjects were satisfied with medical staff's attitude, doctor-patient communication, service mode and service content, "joint satisfiction with the attitude and content"(23.79%), "overall dissatisfaction" (20.18%), and "only no satisfaction with content" (19.77%). The family's economic situation was likely associated with the level of satisfaction. The clients are highly satisfied with the medical staff's attitude, and are little satisfied with efficient service process and effective doctor-patient communication. Another deficiency is the lack of health education and rehabilitation, which need strengthen.2. Needs assessment and utilization for CHSThis convenient CHS was provided for the middle-aged and elderly. And the main common disease was chronic. The results of quantitative and qualitative research showed that CHS in the centers and health stations has played very important role for primary health care in the elderly. The elderly can easily access to the necessary drugs, receive timely treatment. Among them, traditional Chinese medicine was reputable treatment by the elderly based on the interview. Moreover, patients' needs were that improvement of staff's skills and technology, and increase of the number of community health workers.Section III: The Analysis of Providers on CHS1. Description of the human resource of CHS institutions and the analysis of job satisfaction among medical staffA total of 1,136 staff in CHS institutions took part in the survey. The health human resources of CHS institutions showed the following characteristics: The ratio of male to female was 1:4; doctors accounted for 32.0%, 40.8% of subjects for nurses, 11.4% for preventive care staff and 15.9% engaged in management, pharmacies and logistics. With regard to educational level, 51.5% of doctors have a bachelor degree or above level and 83.8% for college and above. The majority of age were young(under 30 years old) and middle age (31-40 years old) and the proportion of general practionioner was no significant difference in the clinic, ward and GPST; Preventive care staff worked more in GPST, the proportion of the age was little difference between young, middle age and old age, the majority of educational degree was the college that below doctors' leve; Among nurses, the majority of age were young and middle age, but the nurses of over the age of 41 usually worked in out-patient and GPST. The majority of education was Nursing School. The nurses in the ward earned less than nurses at the out-patient and GPST. Generally, the proportion and educational level of human resources in CHS institutions exceeded the state's basic level.Each item of intrinsic and external satisfaction was high via descriptive analysis of job satisfaction in addition to income level. According to structural equation model analysis of job satisfaction and standard regression estimate, factors affecting intrinsic satisfaction would be education (-0.126, negative correlation), income (0.103, positive correlation) and the ones affecting external satisfaction would be income (0.146, positive correlation), work type (0.119, positive correlation) and education (-0.116, negative correlation). In addition, "Proposal regarded important level", "work in diversity", "assumed responsibility" played the big role on intrinsic satisfaction, while "management style", "relations between leader and employee" and "job security" much more effect on the external satisfaction.2. Needs assessment and evaluation for the job in CHSThe results of questionnaires and interviews revealed that more than 90% of the medical staff has received job-related training including knowledge, attitudes and skills through various types and forms. However, the staffs' demands and suggestions showed that still need to enhance specialty learning and training for the sake of strengthening level of medical technology. In addition to the forms of previous training and vocational education, they also would practice in the top hospital for further studies to improve medical level. Furthermore, although most doctors performed profession ethics in order to meet patient needs and provide treatment, care and prevention efforts, some staff had a negative perception for clinical prevention or public health efforts, say, basic public health work "is largely meaningless". Finally, there were three main difficulties proposed by community health workers. The first was "heavy workload and lack of systematic preventive work". The second was "low social status for community health workers" and "media's inappropriate publicization for CHS". The third was not enough support for computer technology, health records management.3. The SWOT analysis for GPSTThrough SWOT analysis, we found strengths for GPSTs were their team unity, as well as skilled personnel, standard equipments and establishment, convenient site location, good services content and management. Opportunities were the support of external resources including the community committees, community health centers, and clients in community, the supervision from parent department, government policies and investment in social context. All these would be useful to carry out and improve CHS. Section IV: The Analysis of Process and Pattern on CHS1. The clinic process for patientFor outpatient process, waiting time was generally an average of 3 minutes, the longest time of up to 15-50 minutes. The time of diagnosing and prescribing was an average of 3-5 minutes and the longest of 5-10 minutes. Doctor's and nurses' attitude were kind during the entire service process. However, the process between payment via medical card and obtainment of medicines in health stations stayed time and was the longest tiem of the whole process. Because the payment and medicine needed to implement in community health centers and patients had to visit health stations once again in the afternoon for their medical card and medicines.2. The general process among medical staff in GPSTThe division of labor in GPST personnel was in accordance with their respective professional. The core work of the caption of team was management and medical work. The main work between general practitioner (GP) for medicine and GP for Chinese medicine was out-patient work, followed by the chronic disease management and the "six-cares", which were visit and consult for the elderly, the widow in the army, the disable. Preventive care staff deliverd public health work. The main work of nurses was also medical work-based. Medical staff primarily focused on the year in January, March, April, September and October. The busiest time of the year for medical work was often in March, because a new round medical insurance of health-care cycle in Shanghai city was about to start, and with the disease in the winter and spring after the turn of a certain extent cyclical episodes. Second, the busy pre-holiday period was the patient's drug preparation for travelling and seasonal periodic changes of diseases during this period. For public health was concerned, the busiest period for the year was from January to March due to seasonal changes in the emergence of new disease, and the beginning of new tasks assigned by Disease Prevention and Control Center in the region. In addition, the higher authorities was before appraisal and inspection which medical and public health would be busy with collating work records and information cross-checking.3. The assessment for service content and processIn the process of out-patient services, good work delivered would be "blood sugar tests," "report diagnostic results," "outpatient infusion therapy" and "drugs distribution"; the principal work improved would be "telephone consultation," " diagnosis and prescription". Moreover, other good work were mainly "domestic sickbed", "case record", "home visits", and "telephone follow-up and postpartum visits". These services such as "new chronic invalid management", "chronic disease management," "six-cares", "eyesight-protection for the elderly", "monitoring and evaluation for process", "patient and his family's health education", "family planning" and "filing" could be improved. The tasks with serious problems were the "prevention for mental disease", and "follow-up for cancer patient". In addition, some complaints among patients were primarily of "filing", "prevention and control for infectious disease", "follow-up for cancer patient", "prevention for mental illness". Some service processes need to reorganize and improve.4. The characteristic of work pattern and management features for GPSTGPST was generally composed by "GP + preventive care staff + nurse" and the number of personnel in communities depended on the range of services vary. Work pattern in GPST indicated the following characteristics: 1) GP was usually the GPST captain; 2) The distribution of tasks was work in accordance with the household registration for doctors that GP was responsible for all work and their respective speciality that GP was responsible for clinical work, preventive care staff responsible for public health, nurses responsible for injection treatment; 3) The tasks of Chronic disease management and the "six-cares" as work shared by GPST members, were allocated according to the the section of community or number of jobs—GP commitment to chronic disease management and the " six-cares ", preventive care staff to take on chronic disease management, nurse bear the "six-cares"; 4) The work of chronic disease management was divided into the follow-up for patients and the input and sort of data. Furthermore, management features were mainly the support of human resource and equipment, the organization of health education and centers involved in chronic disease management.5. SWOT analysis for CHS and development strategiesBased on SWOT analysis Of community health centers and health stations, the six strategies were proposed for the development of CHS: strategy 1 is to strengthen quality management of community health services; strategies 2 is to upgrade the management level for CHS; Strategy 3 is to foster community health workers with high quality; Strategy 4 is to extend advantages of GPST and optimizie resource allocation; strategy 5 is to develop information systems of community health service; Strategy 6 is to stress participatory from residents, families and organizations in the community.