founding and evaluating efficiency of training model to transfer technology from polyclinic hospital of hoa binh province to district hospitals

MINISTRY OF EDUCATION AND TRAINING - MINISTRY OF HEALTH NATIONAL INSTITUTE OF HYGIENE AND EPIDEMIOLOGY TRUONG QUY DUONG CONSTRUCTION AND EFFECTIVENESS EVALUATION MODEL TECHNICAL TRANSFE

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

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

ABBREVIATIONS AND ACRONYMS

DLI : Doctor Level I

DLI, DLII : Doctor Level I, Doctor Level II

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

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

- 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

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

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

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)

Kim Boi Tan Lac

2006

Total times of inpatient clinic in district GH 7124 6359

Times of inpatient clinic average/100/year 6.5 8.2

2007

Total times of inpatient clinic in district GH 9673 6357

Times of inpatient clinic average/100/year 8.7 8.4

2008

Total times of inpatient clinic in district GH 10777 8859

Times of inpatient clinic average/100/year 9.6 11.6

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

(p>0.05)

Increa

sed 0.33%

/ year

Increased 2.0% (p<0,001

Increase

d 1.29% / year Increased

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

(p<0.05)

Increased

0.62% /year

* In 12 kinds of disease transited from two district GHs up to province GH, in 3

years (2006-2008): Surgery was the highest percentage (21.02 to 25.79%),

resuscitation (7.51 - 11.40%), neonatal morbidity (7.03 to 11.40%), obstetric pathology

(9.71 to 10.81%), pediatric pathology (9.33 to 9.79% ), general internal diseases (11.27

to 7.91%), ophthalmology disease (6.10 to 6.64%); other diseases below 4%

* Referral patient were diagnosed in two HO different from Hoa Binh GH: Kim

Boi GH had 298/3131 patient times (9.52%) were diagnosed with a difference Tan Lac

GH had 103/1175 patient times (8.77%) differential diagnosis In 2006 both HO had

different diagnostic rate was the highest 19.53% and 12.07%

3.1.2 Ability to provide medical services of the two districts GH

3.1.2.1 Current status of professional personnel

Table 3.13 The payroll norms under the working hours of

Tan Lac and Kim Boi GH (2007)

District GH Unit Under working

hours

Circular No MOH-MI

08/2007/TTLT-Kim Bôi

As compared with the payroll norms first line: Polyclinic facilities got Class III

standards prescribed in Circular No 08/2007/TTLT-MOH-MI of joint MOH-Ministry

of the Interior The two hospitals only got 50% of the prescribed norms

Table 3.14 Division rate departments, the professional parts of two HO (2007)

Department Kim Boi

- Kim Boi GH structure reached the regulations of Circular 08; Tan Lac GH

structure for clinical high and low for subclinical, pharmaceutical; Management,

administrative structure in two hospitals were lower than the regulations The ratio of

doctors / nurses, midwives, nurses, technicians of Tan Lac GH structure reached one

third as prescribed This ratio in Kim Boi GH is 1/2,25 Other indicators did not meet

regulations

3.1.2.2 Professional activities of the hospital

Table 3.15 Professional activities of two hospitals in 3 years (2006-2008)

imaging tests 2871 3248 3583 3234±356 3056 3219 3427 3234±186

* Results of treatment in two hospitals in three years (2006-2008): The rate of recover treatment in two hospitals over 80%; mortality rate is 0.07%

* Ability to perform technical services in clinical and subclinical basically

classified for district HOs Kim Boi GH had made 212/289 (73.4%) services; Tan lac

GH had made 221/289 (76.5%) services Both GHs had full subclinical technique services in technical distribution

* Ability to meet the clinical equipment, subclinical equipment served by two district HOs in distribution of technical: The basic equipment for first aid, internal

treatment, surgery and subclinical in both HOs were sufficient in technical distribution Except for the equips supported for essential newborn care at two hospitals were not available

3.2 Develop and evaluate the 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 Department to the

communal health stations Provincial GH had Direct line Office and its branches; district GH had a direct line subcommittee

* Construction training management cycle: Construction Training cycle with 14

specific steps, each step had tools to collect specific 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 focus on a number of fields such as essential newborn care , the bone surgery, caesarean section, operating on the surgical pathology of the uterus, ovaries, resuscitation, anesthesia recovery

3.2.2 Initially evaluate the effectiveness of the model

Table 3.20 Professional activities of two HOs (before - after intervention)

Index

Average 3 years (2006-2008)

Average 2 years (2009-2010)

Comparison the number of times (Increased,reduced) Kim

Boi

Tan Lac

Kim Boi

Tan Lac

Kim Boi

Tan Lac

No of beds in plan 103 77 135 93 Increased Increased

Productivity of using beds

treatment (day) 5.03 5.5 4.8 5.2 Reduced 0.23 Reduced 0.3

Total No of tests 38512 48841 39523 50472 Increased 1.03 Increased

Average 2 years (2009-2010)

Comparison of times (Increased,Reduced) Kim

Boi

Tan Lac

Kim Boi

Tan Lac

Kim Boi

Tan Lac

referral patient 1044 392 528 376

Reduced 2.0

Reduced 1.04Percentage (%) of times

referral patient

10.2 5.17 5.24 4.40 Reduced

1.95

Reduced 1.18 Comparison of rate (%)

referral patient times

Reduced

4.96%

Reduced 0.77%

Total patients on referral from 2 BV BVDK Hoa Binh reduced 2.0 times and 1.04 times Patient referral rate of 2 BV decreased 4.96% (p1-3 <0.001; EIT = 48.63%) and 0.77% (p (2-4) <0.01; EIT = 14.89% )

Table 3.22 Rate of some diseases referred from Kim Boi GH to Hoa Binh province GH

(before - after intervention)

Clinical disease

Average 3 years (2006-2008)

Average 2 years (2009-2010) P

(EI %)

Reduction level

PT Inferral PT Inferral

Emergency&intensive

care (%)

255 (100.0)

78 (30.59)

279 (100.0)

58 (20.79)

<0.001 (32.05) 1.3 times Obstetrics

(%)

918 (100.0)

101 (11.0)

1007 (100.0)

78q (7.75)

<0.01 (29.54) 1.3 times Paediatrics (%) 3098

(100.0

97 (3.13)

3395 (100.0)

72 (2.12)

<0.001 (32.26) 1.3 times Neonatal diseases

(%)

73 (100.0)

73

(100.0)

80 (100.0)

14 (17.50)

<0.001 (82.50) 5.2 times Emergency & Intensive care reduced 1.3 times (p <0.001; EIT = 32.05%); Obstetrics decreased 1.3 time (p <0.01; EI = 29.54%) Paediatrics decreased 1,3 time (p

<0.001; EIT = 32.26%); Neonatal decreased 5.2 times (p <0.001; EIT = 82.50%)

Table 3.23 Rate of some diseases referral from Tan Lac GH to Hoa Binh province GH

(before - after intervention)

Clinical disease

Average 3 years (2006-2008)

Average 2 years (2009-2010) (EI %) P Reductio n level

PT Refered PT Refered

Emergency&Intensiv

e care (%)

200 (100.0)

45 (22.5)

236 (100.0)

29 (12.29)

<0.001 (45.38) 1.6 times

Obstetrics

(%)

216 (100.0)

42 (19.4)

257 (100.0)

29 (11.28)

<0.001 (41.86) 1.4 times

Paediatrics

(%)

2163 (100.0 (1.76) 38 (100.0) 2569 (1.25) 32 (28.98) <0.01 1.2 times

Neonatal

(%)

45 (100.0) (100.0) 45 (100.0) 53 (13.20) 7 (86.80) <0.001 6.4 times

The rate of referral average 2 years (2009-2010) compared with average 3 years

(2006-2008):-Emergency & Intensive Care reduced 1.6 times (p<0.001; EIT = 45.38%); Obstetrics reduced 1.4 times (p <0.001; EIT = 41.86%); Paediatrics