Stimulants économiques et utilisation des services médicaux

Having demonstrated that the traditional economic model of the market cannot be used in its present form to understand what is happening in the field of medical services, a presentation will be made of the factors affecting the behavior of physicians as purveyors of services, thus showing the importance of analyzing the influence of economic incentives on physician behavior. The analysis consists of measuring the change in the practice profiles of physicians from 1971 to 1973, and evaluating the influence of the fee schedule on this change. This research allows us to show that the personal characterictics of physicians, the characteristics associated with the organization of their practice and the area in which they practise are only very slightly related to the changes in the mix of the medical services produced by physicians; that the change in the profile of practice cannot be associated with changes in the populations' needs, and that the financial incentives incorporated in the fee schedule have been found to be mainly responsible for the shifts observed in the profiles of practice. We conclude by showing how these results are compatible with the hypothesis that physicians can influence demand for medical services.

Stimulants économiques et utilisation des services médicaux

Having demonstrated that the traditional economic model of the market cannot be used in its present form to understand what is happening in the field of medical services, a presentation will be made of the factors affecting the behavior of physicians as purveyors of services, thus showing the importance of analyzing the influence of economic incentives on physician behavior. The analysis consists of measuring the change in the practice profiles of physicians from 1971 to 1973, and evaluating the influence of the fee schedule on this change. This research allows us to show that the personal characterictics of physicians, the characteristics associated with the organization of their practice and the area in which they practise are only very slightly related to the changes in the mix of the medical services produced by physicians; that the change in the profile of practice cannot be associated with changes in the populations' needs, and that the financial incentives incorporated in the fee schedule have been found to be mainly responsible for the shifts observed in the profiles of practice. We conclude by showing how these results are compatible with the hypothesis that physicians can influence demand for medical services

Le regroupement des hôpitaux selon leur production : base d’évaluation de leur performance

The review of the budgetary bases of hospitals in Quebec is conducted in three stages: (1) classifying hospitals; (2) evaluating the performance of human and material resources used in each hospital as well as comparing this performance with the average performance of the peer-groups; (3) using the results to establish a correcting mechanism for an adequation redistribution of a portion of the total budget among individual hospitals. The realism of this process of budgetary review lies in the possibility of appropriately classifying the hospitals according to their output. In this paper, along with a short presentation, at the end, of the two last steps of the review process, we focus on the classification itself. We define firstly what constitutes the hospital's output, which is a mix of inpatient services (main variable), outpatient services, research and teaching, as well as environmental variables influencing the output. Then we describe the classification technique, which uses two different similarity indices, one for the distribution of patient-days by category of diagnosis (ICDA, 8th revision), and the other for all other variables; these indices are incorporated in a hierarchical sorting strategy based on the optimization of an objective function. This method is subsequently applied to the acute short-term hospitals of Quebec, using 1976-77 data, and the different resulting eight groups of hospitals are broadly described. In the conclusion, are indicated some suggestions for improving the classification and the budget reviewing mechanism itself

Les urgences psychiatriques dans la région du Montréal métropolitain : quelques différences entre les hommes et les femmes

Le thème du présent numéro vise à caractériser la situation des femmes à l'égard de certains aspects de la santé mentale. C'est une occasion de présenter certaines données d'une recherche sur les urgences psychiatriques effectuée dans la région du Montréal métropolitain. Cet article comporte trois parties. Dans une première partie, on décrira d'une manière générale les patients considérés comme « urgences psychiatriques » dans la région de Montréal, selon certaines caractéristiques socio-démograhiques et économiques et ensuite selon les différents types de détresse psychiatrique. Dans une deuxième partie, un portrait plus détaillé de la clientèle de l'urgence psychiatrique sera brossé en mettant en relief les différences entre la clientèle féminine et la clientèle masculine. Enfin, dans une troisième et dernière partie, seront présentées des données relatives à une dimension importante de l'intervention médicale en psychiatrie d'urgence, à savoir les premières décisions prises par les professionnels de la santé de service à l'urgence en réponse à cette demande.This article presents a general description of the clientele requiring emergency psychiatric services in the Greater Montreal area, with a particular emphasis on the differences between the characteristics of the female and of the male clientele of these emergency services (demographic variables, diagnosis, treatment and disposition variables)

Analyse descriptive des urgences psychiatriques dans la région du Montréal métropolitain

Cet article résume la première partie d'une recherche descriptive sur les urgences psychiatriques dans la région métropolitaine de Montréal. Tout d'abord, nous exposons le contexte dans lequel se situe l'étude et les objectifs poursuivis ; dans un deuxième temps, nous effectuons une brève description des principaux aspects méthodologiques de la recherche. Dans un troisième temps, nous présentons les données relatives au nombre d'urgences psychiatriques et à la répartition de cete demande de soins selon les centres hospitaliers du Montréal métropolitain. Un second article traitera des principales caractéristiques de la clientèle psychiatrique qui requiert les ressources d'urgence : âge, sexe, état civil, catégories socio-professionnelles, types de détresse psychiatrique, profils d'utilisation antérieure, etc.In. September 197S1, a research team from the Department of Health Administration of the University of Montreal, completed a research study on psychiatric emergencies financed by the Planning section of Quebec's Ministry of Social Affairs. The purpose of this research was on the one hand, to measure the importance of psychiatric problems in the emergency services of hospital centers in Montreal's metropolitan region (22 institutions) and, on the other hand, to describe the characteristics of patients who have access to these emergency services for the purpose of psychiatric treatment.This article summarizes the first section of this research study. Firstly, the authors explain the problem underlying the study, as well as the objectives pursued. Subsequently, a brief description of the research is made, according to its major methodological features. Finally, in the third section, data relative to the number of psychiatric emergencies and to the distribution of this care demand in Montreal's hospital centers, are presented.A second article will deal with the main characteristics of the psychiatric clientele requiring emergency resources i.e. age, sex, marital status, socio-professional categories, types of emotional distress, profiles of past-utilization of services (etc.)

Évaluation de la réforme des services psychiatriques destinés aux adultes au pavillon Albert-Prévost 1

Cette étude de cas analyse l'implantation de la réforme du dispositif de soins destinés aux clientèles adultes du Pavillon Albert-Prévost. Le niveau de mise en oeuvre et les effets du nouveau dispositif ont été mesurés, et l'influence du contexte politique et structurel a été analysé. À la fin de la période d'observation, la mise en oeuvre de l'intervention n'était pas encore complétée mais elle avait déjà entraîné des effets intéressants, surtout en ce qui concerne l'accessibilité et l'efficience. Ces effets furent atteints par des mécanismes dont certains n'avaient pas été prévus au projet de réforme. Les auteurs ont également identifié un ensemble de facteurs contextuels qui ont facilité ou ralenti la mise en oeuvre de la réforme et la réalisation des effets attendus.This case study analyzes the implementaion of the reform of care destined to clienteles at the Pavillon Albert-Prévost. The level of implementation and the effects of the new systme have been measured and the influence of the political and structural contexts have been analyzed. At the end of the observation period, the implementation of the intervention was not yet completed but had already entailed interesting effects especially concerning access and efficiency. These effects were achieved through some mechanisms not previously planned for in the reform project. The authors have also identified several environmental facors facilitating the implementation of the reform and the realization of expected effects.Este estudio de casos analiza la implantación de la reforma del dispositivo de cuidados destinado a la clientela adulta del Pabellón Albert-Prévost. Se han medido, el nivel de puesta en marcha, los efectos del nuevo dispositivo y la influencia del contexto político y estructural se analizaron. Al final de periodo de observación, la puesta en marcha de la intervención no se había completado pero ya había traído efectos interesantes, sobre todo en cuanto a la accesibilidad y la eficacia. Estos efectos fueron alcanzados por mecanismos, de donde algunos no habían sido previstos en el proyecto de reforma. Igualmente, los autores ha identificado un conjunto de factores contextuales que han facilitado o retrasado la puesta en marcha de la reforma y la realización de los efectos esperados

L’intégration des services sur une base locale : acquis et limites

Cet article rend compte d'une expérience locale d'intégration des services auprès d'une clientèle souffrant de troubles mentaux. L'expérience s'est déroulée dans une région rurale entre 1998 et 2001 et a été financée par le Fonds pour l'adaptation des services de santé (FASS). Les auteurs décrivent le contexte particulier de l'expérimentation, le modèle d'intervention qui, fait particulier, comprend une intégration des services de santé au niveau populationnel ainsi que des interventions spécifiques pour la clientèle de la santé mentale. Les auteurs procèdent ensuite à l'évaluation de cette expérimentation et plus particulièrement son implantation en s'appuyant sur le concept de partenariat. Les relations dyadiques entre les acteurs institutionnels, non institutionnels et les personnes utilisatrices sont ainsi examinées. Après avoir mis en évidence les avantages d'une telle expérimentation locale, ils discutent des limites et des enjeux particuliers de ce projet dans le contexte de la santé mentale.Service integration on a local basis : advantages and limits This article describes an experience of integration of services to people with mental health disorders on a local basis. The experience took place in a rural region between 1998 and 2001 and was funded by the Fonds pour l'adaptation des services de santé (FASS). The authors describe th specific context of the experience, the intervention model which includes integration of health services on a population level as well as specific interventions for mental health patients. The authors then evaluate the experience and more particularly, its implementation on the basis of the concept of partnership. Dyadic relationships between institutional, non institutional protagonists and consumers are examined. After emphasizing the advantages of such an experience, the authors discuss the limits and particular stakes of such a project in the context of mental health.La integración de servicios sobre una base local: adquiridos y limites Este artículo da cuenta de una experiencia local de integración de servicios con personas que padecen de problemas mentales. La experiencia se efectuó en una región rural entre 1998 y 2001 y ha sido financiada por el Fondos para la adaptación de servicios de salud (FASS). Los autores describen el contexto particular de la experimentación, el modelo de intervención, cual, hecho particular, incluye una integración de servicios de salud al nivel poblacional aisi que de intervenciones específicas para la clientela de salud mental. Los autores proceden despues a una evaluación de esta experimentación y más particularmente, su establecimiento, apoyandose sobre el concepto de colaboración. Las relaciones dyadicas entre los actores institucionales, non institucionales y las personas utilizadoras estan examinadas. Ponen en evidencia las ventajas de tal experimentación local y discuten de las limites y de cuestiones particulares de este proyecto en el contexto de la salud mental.Integração dos serviços prestados localmente: conquistas e limites Este artigo trata de uma experiência local de integração dos serviços prestados junto a uma clientela que sofre de problemas mentais. A experiência foi realizada em uma região rural entre 1998 e 2001 e foi financiada pelo Fundo para Adaptação dos Serviços de Saúde (FASS). Os autores descrevem o contexto específico da experiência, o modelo da atuação que, especificamente neste caso, inclui uma integração dos serviços de saúde em nível popular e as atuações específicas da clientela de saúde mental. Os autores fazem em seguida uma avaliação desta experiência e, mais especificamente, de sua implantação, apoiando-se no conceito de parceria. Eles examinam as relações diádicas entre os atores institucionais, não institucionais e os usuários. Depois de evidenciar as vantagens desta experiência local, eles discutem sobre os limites e as questões específicas deste projeto no contexto da saúde mental

Does accreditation stimulate change? A study of the impact of the accreditation process on Canadian healthcare organizations

<p>Abstract</p> <p>Background</p> <p>One way to improve quality and safety in healthcare organizations (HCOs) is through accreditation. Accreditation is a rigorous external evaluation process that comprises self-assessment against a given set of standards, an on-site survey followed by a report with or without recommendations, and the award or refusal of accreditation status. This study evaluates how the accreditation process helps introduce organizational changes that enhance the quality and safety of care.</p> <p>Methods</p> <p>We used an embedded multiple case study design to explore organizational characteristics and identify changes linked to the accreditation process. We employed a theoretical framework to analyze various elements and for each case, we interviewed top managers, conducted focus groups with staff directly involved in the accreditation process, and analyzed self-assessment reports, accreditation reports and other case-related documents.</p> <p>Results</p> <p>The context in which accreditation took place, including the organizational context, influenced the type of change dynamics that occurred in HCOs. Furthermore, while accreditation itself was not necessarily the element that initiated change, the accreditation process was a highly effective tool for (i) accelerating integration and stimulating a spirit of cooperation in newly merged HCOs; (ii) helping to introduce continuous quality improvement programs to newly accredited or not-yet-accredited organizations; (iii) creating new leadership for quality improvement initiatives; (iv) increasing social capital by giving staff the opportunity to develop relationships; and (v) fostering links between HCOs and other stakeholders. The study also found that HCOs' motivation to introduce accreditation-related changes dwindled over time.</p> <p>Conclusions</p> <p>We conclude that the accreditation process is an effective leitmotiv for the introduction of change but is nonetheless subject to a learning cycle and a learning curve. Institutions invest greatly to conform to the first accreditation visit and reap the greatest benefits in the next three accreditation cycles (3 to 10 years after initial accreditation). After 10 years, however, institutions begin to find accreditation less challenging. To maximize the benefits of the accreditation process, HCOs and accrediting bodies must seek ways to take full advantage of each stage of the accreditation process over time.</p