TA for Capacity Building for Tertiary Care Services An EU-funded project managed by the European Agency for Reconstructi

1. Republic of Serbia MINISTRY OF HEALTH • Day Surgery/ Day Hospital: • Challenging existing models of service delivery • in a transitional country • Jekić I.M, • Katrava A, Boulton G, Milojković A,Andrejević V, Koumpis N, • Đukić V*, Peško P*, Dmitrović T*, Drašković D**, Dujmović F**, Trenkić S***,Pavlović R**** • EAR/EU SOFRECO Technical Assistance-TA Team, Belgrade • * Clinical Centre of Serbia, Belgrade • ** Clinical Centre of Vojvodina, Novi Sad • *** Clincal Centre of Niš • **** Clinical Centre of Kragujevac TA for Capacity Building for Tertiary Care Services An EU-funded project managed by the European Agency for Reconstruction

2. Context • Day Surgery/Day Hospital models of service delivery are in their early stage in Serbia. • The health reform targets call for 3-5% annual increase in ambulatory services. • The EU/EAR Projectprovided to the Ministry of Health-MoH has been charged with • reforming tertiary care services and • implementing an EIB loan of EUR 200M in the beneficiary institutions: the Clinical Centres in Belgrade, Novi Sad, Nis and Kragujevac for their rehabilitation and strategic development. • Four largest university hospitals in Serbia together have • over 220,000 inpatients • 120,000 surgeries annually • rather low day surgery/day hospital cases rates. TA for Capacity Building for Tertiary Care Services An EU-funded project managed by the European Agency for Reconstruction

3. International surveys – Country benchmarks for day surgery activity Background • International Association for Ambulatory Surgery & OECD • Results of World Wide Day Surgery Activity 2003 • 18 countries or regions, 37 procedures • In most countries day surgery activities are within public hospitals (In USA where activity is very high, the percentage of private free standing units is also very high) • Reimbursement systems are very different • USA, Canada and Scandinavian countries have high percentage of day surgery procedures • Countries having high rate of day surgery in some specialties may have significantly low rate in other specialties TA for Capacity Building for Tertiary Care Services An EU-funded project managed by the European Agency for Reconstruction

4. International variations in availability and diffusion of day surgery Background Micro level • Patients or physicians may not want, or may not be able to use day surgery • Hospital characteristics, such as the number of hospital beds Macro level • Health care system characteristics, such as financing and insurance influence the shift to day surgery TA for Capacity Building for Tertiary Care Services An EU-funded project managed by the European Agency for Reconstruction

5. Key factors to Consider as Care Shifts to Day Surgery + Outpatient Background • Impact of Competition • Private physician offices • Cost • Increased supply, technology costs • Length-of-stay cost savings • Payer mix • Health Insurance coverage • Ancillary Demand • Related billable volume • Market Growth • Potential • Improve Outcomes • Reduced risk and pain TA for Capacity Building for Tertiary Care Services An EU-funded project managed by the European Agency for Reconstruction

6. Background Slow Pace of Clinical ProliferationTechnology-Driven Outpatient Growth 100% Percentage Outpatient 0% Time TA for Capacity Building for Tertiary Care Services An EU-funded project managed by the European Agency for Reconstruction

7. Background Trend in take up of day surgery TA for Capacity Building for Tertiary Care Services An EU-funded project managed by the European Agency for Reconstruction

8. Background • Even when the evidence for change to clinical practice is so strong and seemingly self evident, there is no guarantee that it will be adopted. • This is a classic management of change issue that involves • “soft” factors such as professional attitudes • “hard” factors such as data / resources / appropriate funding system from the Health Insurance Fund - HIF as an incentive for this change. • Currently, HIF funds the hospital based on a “hospital day” and therefore operating budget disincentives to “shift” to day surgery because the HIF will not reimburse the hospital for a day case. • This causes certain deviation/adjustments in recording/invoicing of the day surgery cases towards the HIF, resulting in lower rate of recorded day surgery cases that have really been performed TA for Capacity Building for Tertiary Care Services An EU-funded project managed by the European Agency for Reconstruction

9. Methods • Over past seven years, the Clinical Centres have still been operating under • unchanged legislation • unchanged model of service delivery • fixed operating budgets • These represents limitation for the hospitals to respond to increasing demands of emerging ambulatory service delivery model. • The EU/EAR Project is a vehicle with capital investments providing an opportunity • to restructure space for more day surgery and day hospital • to facilitate professionals buy-in to this model of service delivery • to motivate MoH to support this change due to systemic improvement in quality of care and lowering costs • to influence MoH and HIF to change financing models. TA for Capacity Building for Tertiary Care Services An EU-funded project managed by the European Agency for Reconstruction

10. Methods - Organization of day surgery • Accommodation for day surgery • Most cost-effective option is a self-contained day surgery unit, with its own admission suite, theatre and recovery area together with administrative facilities. • Less satisfactory arrangement is a day case ward with patients going to the main operating room • Management of the day surgery unit • Day surgery needs a rigorous management structure including • lead clinician • day surgery manger/senior nurse • other staff • Changes of working practices • Specific training for the surgeon and anesthetist in day surgery techniques • Local incentives, such as the availability of enhanced resources to those who shift treatment to day surgery • Dedication of theatres for day case are preferred for better output, compared to theatre/ward mix with inpatient surgery • The advantages to patients • Opportunities to see and experience day surgery TA for Capacity Building for Tertiary Care Services An EU-funded project managed by the European Agency for Reconstruction

11. Methods Research within the Clinical Centers • Research was conducted as • qualitative questionnaire of staff • quantitative/qualitative measurement of operating facility utilization • Research covered • 112 operating theatres • over two weeks period • analyzing over 3000 surgical interventions • Qualitative questionnaire (anonymous) was distributed • among top and medium management in all 4 Clinical Centers • covering 320 managers of different level TA for Capacity Building for Tertiary Care Services An EU-funded project managed by the European Agency for Reconstruction

12. Results • It is an internationally accepted standard that 70% of elective surgery cases can be undertaken in day setting. • In 2008, specific annual targets for 25 selected procedures that can be done safely and effectively as day cases will be set in a step-wise fashion. • Results of the survey • There is no formalized day surgery in Serbia for most of procedures • There is uneven and non systemic development of day surgery in CC’s • There is a different understanding of day surgery definition and procedures between medical employees • Still, there is awareness of day surgery importance and willingness to change towards day surgery • Survey data shows deviation between recorded and actual day services provided • There are no financial incentives for providers to shift to day surgery in spite all other benefits • Expected list of procedures for day surgery is very similar with UK basket of 25 procedures TA for Capacity Building for Tertiary Care Services An EU-funded project managed by the European Agency for Reconstruction

13. Results There is a potential to carry out more day surgery and elective operations within current resources by redistributing and dedicating theatres improving scheduling reducing cancellations decreasing gaps between patients improving the management of existing theatre resources. However There is no functional scheduling and reporting system for utilization There is no theatre/ward booking system prior to admission of patients; There is no measurement of utilization of operating facilities; Members of OR teams are not fully trained for day surgery work flow Still There is evidenced increase in day surgery in Serbia from 2002. Thorough Action plan must be implemented in order to reach targets in day surgery TA for Capacity Building for Tertiary Care Services An EU-funded project managed by the European Agency for Reconstruction

14. Results Observation by hospital staff for improvements needed in development of day surgery • Space • Equipment • Change of financing pattern • Training and education of manpower • Improvement of recording/measurement procedures TA for Capacity Building for Tertiary Care Services An EU-funded project managed by the European Agency for Reconstruction

15. Results • Given their magnitude and high case-load, four largest university hospitals in Serbia offer a large area for improvement • in quality of care • decreasing hospitalization rates and ALOS • increasing patient satisfaction • decreasing cost per patient. TA for Capacity Building for Tertiary Care Services An EU-funded project managed by the European Agency for Reconstruction

16. Results • In each Clinical Centre Work Groups for Day Surgery / Day Hospital were formed to • analyze their existing service delivery model and patient flows to be able • to meet the MoH target of average 3-5% annual increase in ambulatory care. • Some preliminary models of activity-based financing of day procedures such as • chemotherapy • cataract procedures • pace-makers • cardiac catheterizations are already in place. TA for Capacity Building for Tertiary Care Services An EU-funded project managed by the European Agency for Reconstruction

17. Conclusions • Defining procedure-specific annual percentage rates on the five year period (2008-2012) basis • Developing an implementation plan with different targets for each of the 25 potential day cases have been done (eg. 30% of cataract extractions and 20-30% of hernia repairs as day cases in the first year), • Mentioned should secure sustainable shift towards ambulatory care model. TA for Capacity Building for Tertiary Care Services An EU-funded project managed by the European Agency for Reconstruction