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jandacva, jandacvis momsaxureba da xarisxi 2011 lopota cnobili adamianebi sazogadoebrivi jandacvis Sesaxeb “araferi ar SeiZleba iyos qveynisTvis imaze mniSvnelovani, vidre jandacvaa; qveynis umTavresi sazrunavi unda iyos misi xalxis janmrTeloba” franklin d. ruzvelti (In a report to the New York Legislature, 1931) dRes visaubrebT 1. xarisxTan dakavSirebuli problemebi jandacvis sistemaSi; 2. ra aris samedicino Secdoma, Secdomis tipebi 3. ra aris jandacvis xarisxi – ra aris pacientis usafrTxoeba 4. xarisxis gansazRvrebebi 5. xarisxTan dakavSirebuli problemebis analizi ekonomikuri kuTxiT 6. mTavrobis roli jandacvis sistemaSi xarisxis uzrunvelsayofad 7. xarisxis gasaumjobesebli miznebi 8. ra aqtivobebia saWiro xarisxis gasaumjobeseblad anu jandacvis politika xarisxTan mimarTebaSi ra aris janmrTeloba? “sruli fizikuri, mentaluri da socialuri keTildReoba da ara ubralod daavadebis an sisustis ararseboba” (WHO Constitution) janmrTelobios koncefcia Marc Lalonde 1. 2. definicia – janmrTeloba es aris faqtorTa rezultati, romlebic asocirebuli arian genetikur memkvidreobasTan, garemosTan, individualur cxovrebis wesTan da samedicino momsaxurebasTan. janmrTeli cxovrebis xelSewyobas SeuZlia gaaumjobesos janmrTeloba da Seamciros samedicino momsaxurebis saWiroeba elementebi – a. genetikuri da biologiuri faqtorebi; b. qceviTi (cxovrebis stili) faqtorebi; g. garemo (moicavs ekonomikur socialur da fizikur faqtorebs); d. jandacvis sistemebis organizacia jandacva jandacva es aris kerZo da saxelmwifo seqtorebis saSualebiT sruliad sazogadoebis mcdeloba miRweul iqnas janmrTeloba jandacvis sistemis amocanebi • gaaumjobesos mosaxleobis janmrTelobis mdgomareoba; • akontrolos jandacvis xarjebi; • prioritetebis mixedviT gadaanawilos arsebuli resursebi; • gaaumjobesos momsaxurebis xarisxi; • gadaanawilos momsaxureba Tanabrad mosaxleobis yvela fenaze mTavari amocana uzrunvelyos mosaxleoba adeqvaturi samedicino momsaxurebiT Aadeqvaturi samedicino momsaxureba ras vgulisxmobT adeqvatur momsaxurebaSi? A adeqvaturi Careva niSnavs, roca im maqsimaluri saSualebiT rac konkretul Carevas SeuZlia miRebuli sargeblebi (gazrdili sicocxlis saS. xangrdzlivoba, tkivilis Semcireba fsiqo emociuri, sxva funqciuri gaumjobeseba) aRemateba mosalodnel negatiur rezultatebs (sikvdiloba, avadoba, dakarguli samuSao saaTebi, tkivili da a. S) Chassin MR, Park RE, Kahn KL, Kosecoff J samedicino xarisxi • The Institute of Medicine (IOM) xarisxi romliTac jandacvis servisebi Tanamedrove profesiuli codnis saSualebiT zrdis sasurveli Sedegebis miRwevis albaTobas Department of Health (UK 1997) jandacvis xarisxi aris: • swori qmedebebi (ra) • swor pirovnebebze (vis) • swor dros (rodis) • Dda swori qmedebebi pirvelive Carevisas maRali xarisxis jandacvis politikis safuZvlebi 1. pacientcentruli momsaxureba; 2. adeqvaturi xelmisawvdomoba; 3. adeqvaturi samecniero codna; 4. kompetenturi jandacvis mimwodeblebi; 5. samedicino da finansuri gadawyvetilebebis gamijvna; 6. jandacvis sistemis swori organizacia (efeqtianoba, efeqturoba, swori sakanonmdeblo uzrunvelyofa); jandacvis evolucia: daavadebis mkurnalobidan jandacvamde xarisxze orientirebuli medicinis era xarjebis Semcirebisa da utilizaciis kontrolis era xarjebis kontrolis era 1975 1980 1985 1990 1995 2000 2005 ratom xarisxze orientirebuli era xarisxi - kliSe amerikis medicinis institutis moxseneba im samedicino Secdomebis gamo, romelTa prevenciac SesaZlebeli iyo yovelwliurad amerikaSi iRupeba ufro meti adamiani vidre Sidsisagan, ZuZus kibos an avtokatasrofebisagan saSualod 98 000 – 100 000adamiani weliwadSi IOM Report 1999. samedicino Secdomebis zegavlena • didi britaneTis jandacvis departaments 2000 wlis moxsenebaSi iTqva, rom ubeduri SemTxvevebi xdeba hospitalizirebuli pacientebis daaxloebiT 10 %-Si anu 850, 000 ubeduri SemTxveva wlis ganmavlobaSi. • “xarisxi avstraliis jandacvis sistemaSi” kvlevis mixedviT (romelic gamoica 1995 wels) ubedur SemTxvevaTa sixSire hospitalizirebul pacientebSi 16.6 % Seadgens. • The Hospitals for Europe’s Working Party on Quality Care in Hospitals daadgines, rom evropaSi 2000 wels yoveli meaTe hospitalizirebuli pacienti ziandeboda iseTi dazianebebisgan, romlis prevenciac SesaZlebeli iyo; ra aris Secdoma Secdoma aris dagegmili moqmedebis ar Sesruleba ise, rogorc winaswar iyo gansazRvruli…an Sedegis misaRwevad arsowori gegmis gamoyeneba Secdomis tipebi • aqtiuri • latenturi HealthGrades moxseneba - daskvna • sikvdilobis umetesoba gamowveulia ara personalis arakompetenturobis, aramed sistemuri Secdomebis gamo • adamiani yovelTvis uSvebs Secdomas ara aqvs mniSvneloba Tu rogori ganaTleba da momzadeba aqvs mas…… rogoria industriuli standarti Secdomebis dasaSvebi min. raodenoba • A230 – ze naklebi (wuni, defeqti) 1 milion warmoebul produqtSi anu 0,023% • 5 –ze naklebi yovel 1 milionSi Secdomebi dakavSirebuli finansuri servisebis tranzaqciebTan anu 0,0005 % • ra xdeba jandacvaSi? ra xdeba jandacvaSi 6,000 dan 300,000 mde xarvezi, yovel 1 mlnSi Sesabamisad 0,6 – 30% Source: Kohn, LT, Corrigan, JM, and Donaldson, MS (Eds). ubedur SemTxvevaTa da SecdomaTa sixSire erTiani komisiis mier ganxiluli 2966 ubeduri SemTxveva, ianvari 1995 - dekemberi 2004: 370 sxva adgilas Catarebuli qirurgiuli operaciebis SemTxvevebi; 365 operaciuli/post-operaciuli garTulebebi; 326 wamlismier SecdomebTan dakavSiebuli SemTxvevebi; 221 sikvdili dakavSirebuli mkurnalobis dayovnebasTan; 144 pacientis dacema/waqceva; 124 sikvdiloba patimrobaSi myof pacientebs Soris 107 Zaladoba/gaupatiureba/mkvleloba 85 gadasxmasTan dakavSirebuli movlenebi 84 perinataluri sikvdiloba/dazianeba 57 infeqciasTan dakavSirebuli movlenebi 57 saavadmyofodan gaqcevis Semdgomi sikvdili 51 xanZari 49 anesTeziasTan dakavSirebuli movlenebi ubedur SemTxvevaTa adgili/dawesebuleba ianvari 1995 – dekemberi 2004 General hospital Psychiatric hospital 1942 351 Out-pt behavioral health 159 Psychiatric unit 155 Emergency department 131 95 Long term care facility Ambulatory care setting 67 Home care service 54 Clinical laboratory 6 Critcal access hospital 3 Health care network 2 Office-base surgery 1 0 200 Total for all settings = 2966 400 600 800 1000 1200 1400 1600 1800 2000 ubedur SemTxvevaTa ZiriTadi mizezebi yvela kategoria; 1995-2004 Communication Orientation/training Patient assessment Staffing Availability of info Competency/credentialing Procedural compliance Environ. safety / security Leadership Continuum of care Care planning Percent of 2966 events Organization culture 0 10 20 30 40 50 60 70 80 90 100 sikvdilis SemTxvevebi drois erTeulSi - riskebi • orsuloba • matarebliT mgzavroba 1 5 • saxlSi muSaoba • soflis-meurneobis nawilSi 10 8 muSaoba • • sacobSi yofna • mSeneblobaze muSaoba • frena • hospitalizacia 50 67 100 2000 cudi xarisxis Rirebuleba cudi xarisxis wliuri xarji saS. TiTo dazRveulze • $1,500 pirdapiri jandacvis xarji • $400 - $750 arapirdapiri xarji (mag gacdenili samuSao dReebi) • $1,900 - $2,250 cudi xarisxis MmTliani jamuri saS. xarji jandacvis da cudi xarisxiT gamowveuli xarjebis dinamika wlebis mixedviT 2,5 2,3 jandacvis xarjebi sul 2 1,5 1,4 1 0,7 cud xarisxTan asocirebuli xarjebi 0,69 0,5 0,42 0,25 0 0,2 0,07 1980 1990 2001 2008 cudi xarisxis efeqti Juran Institute, Inc. The Severyn Group, Inc. 2007 problema efeqti 1 wamlebis araswored gamoyeneba 300 mlrd 2 antibiotikebis araswori daniSvna 5 mlrd 3 nozokomialuri infeqciebi 20-60,000 sikvdilis SemTxveva + 18 mlr 4 diabeti 132 mlrd 5 depresia 80 mlrd 6 araadekvaturad namkurnalebi gulis mwvave iSemiuri daavadebebis sikvdilobis SemTxveva yovelwliurad 18, 000 sikvdilis SemTxveva 7 arasworad marTuli gripisa da pnevmokokuri vaqcinacia 10,000 - 20,000 sikvdilis SemTxveva 8 asTmis cudi marTva 18 mlrd 9 gulis qronikuli iSemiuri daavadebebis uxarisxod marTva 10 – 40 mlrd cudi xarisxis gamovlinebebi • resursis zedmetad moxmareba • resursis arasakmarisad gamoyeneba • resursis arasworad gamoyeneba resursis zedmetad gamoyeneba • qirurgiuli procedurebi, testebi, samkurnalwamlo saSualebebi: • mag: histereqtomiebi, kardiokaTeterizaciebi, timpanostomiebi, karotiduli endarteqtomiebi, kardialuri peismeikerebi, gstrointestinaluri endskopiebi, antibiotikebi, sedatiuri saSualebebi, arasteroiduli anTebis sawinaaRmdego saSualebebi resursis zedmetad gamoyenebis mizezebi: kvlevebi uCveneben • zedmeti raodenobis hospitlebi – hospitaluri servisebis rigi procedurebisa da mkurnalobis zedmetad gamoyeneba, • zedmeti raodenobiT eqimebis Tavmoyra garkveul regionSia aseve mizezia zedmeti moxmarebis da jandacvis xarjebis zrdis resursis arasakmarisad gamoyenebis magaliTebi • bevria faqtebi, rom eqimebi ar mihyvebian mtkicebulebebze dafuZnebul gaidlainebs da pacientebi ar iReben diagnostikur da Teerapiul servisebs, wamlebs da procedurebs iseTi daavadebebis dros rogorebicaa g.i.d da diabeti; • gripis da pnevmokouri vaqcinebis administrireba; • skrining testebi depresiis, ZuZus kibos, qlamidiazis dasadgenad rac iwvevs sicocxlis xarisxis daqveiTebas da rig SemTxvevaSi sikvdils. aseTi midgomebis zusti finansuri Sedegi ar aris naTeli resursis araswori gamoyenebis magaliTebi • samedicino Secdomebi yvelaze metad xdeba arasworad gamoyenebis dros: • • • • wamlebi; nozokomialuri infeqciebi; diagnostikuri da qirurgiuli Secdomebi; samedicino aparaturis araswored gamoyeneba • erTi ver SesZlebs garantirebuli gaxados xarisxi – erTs SeuZlia mxolod gazardos albaToba, rom momsaxureba iqneba “kargi” an “ukeTesi” • Avedis Donabediani • saWiroa sistemuri midgoma jandacvis xarisxis struqtura avedis donabedianis mixedviT struqtura procesi kapitaluri Senobebi, aparatura, saSualebebi trenirebuli samed. personali (eqimebi, eqTnebi, administratorebi) sistemis maxasiaTeblebi Sedegi adekvaturi, efeqturi, eTikurad relevantuli, koordinirebuli da socialurad misaRebi samedicino momsaxureba sikvdiloba, avadoba, cxovrebis xarisxi, pacientTa kmayofileba Ppacientis maxasiaTeblebi source: Hopkins: Measuring the quality of medical care, Royal College of Physicians of London, 1991 saxelmwifos roli jandacvis Tavisufali (araregulirebadi) bazari iwvevs uTanabrobas, gazrdil xarjebs sazogadoebisaTvis da sabolood xarjebis zrdas mTavrobisaTvis kerZo seqtori kontrolis (regulaciis) gareSe ar iqneba farTo sazogadoebis interesebis dacvaze pasuxismgebeli da jandcvis bazari ar aris srulyofili da idealuri Sesabamisad… ra aris idealuri bazari? • • • • • Zalaufleba Tanabaria idealuri konkurencia da arCevani sruli informacia fasebi ar aris fiqsirebuli gamWvirvalea Semsyidvelisa da gamyidvelisaTvis ratom aris jandacvis bazari arasrulyofili (idealuri)? • urTierToba momxmarebelsa da mimwodebels Soris ar aris Tanabari • mimwodebels gaaCnia meti informacia • momxmarebeli ar aris srulad informirebuli • momxmarebeli xSirad krizisSia da damokidebulia mimwodebelze • alternatiuli miwodebis resursi xSirad ar aris SesaZlebeli • mimwodeblebs xSirad SeuZliaT fasebis gayinva • mesame piris gadamxdelis (dazRveva) stimulebi cvlis mimwodeblis da momxmareblis gadawyvetilebebs ra unda gaakeTos qveyanam pacientis usafrTxoebis mxriv ? saxelmwifom xeli Seuwyos usafrTxo sistemis Seqmnas • Poka – Yok • 6 Sigma erovnuli nabijebi pacientis usafrTxoebis gaumjobesebisaTvis • • • • • • • usafrTxoebaze fokusirebuli standartebis SemuSaveba Secdomebis Setyobinebis xelSewyoba gamocdilebis gaziareba riskis Semcireba prevenciis gziT pacientebis usafrTxoebaSi CarTva usafrTxoebis yovelwliuri miznebis SemuSaveba TavSeyra, TanamSromloba, ganaTleba • imisaTvis, rom uzrunvelyos xarisxi jandacvis sistemaSi • saxelmwifos erTerTi mTavaria funqciaa areguliros jandacvis bazari sistemis martivi xedva ratom vakeaTebT rasac vakeTebT? rogor vakeTebT rasac vakeTebT rogor gavaumjobesoT rasac vakeTebT? jandacvis regulacia • 1970 iani wlebi mimowodeblis qcevis maregulirebeli decentralizirebuli programebi (jandacvis saagentoebi, saWiroebis serTifikatebi, biujetebi) • 1980 iani wlebi metad centralizirebuli regulaciebi (peer review organizaciebi, samedicino praqtikis gaidleinebi) da biujetebi (medicare biujeti, prospeqtuli) • gaZlierda qceviTi regulaciebis saxiT naklebad biujeturi regulaciebi jandacvis regulacia II • yvela dasavluri qveynebi aregulireben TavianT jandacvis sitemebs; • yvela (amerikis garda) aRiarebs saWiroebas centraluri mTavrobis mier myari magram naTeli wesebis dawesebas Semsyidvelebis, mimwodeblebis da momxmareblebisTvis; • yvelas esmis, rom mesame piris gadaxdisa da exstensiuri benefitebis kombinacia sxva SSesaZleblobas ar izleva. jandacvis regulacia III • umetesi dasavleTis qveynebi strategiul aqcents akeTeben biujetur regulaciebze (SeTanxmebuli fee eqimebTan, globaluri biujeti saavadmyofoebs. es sazogadoebebi naklebad arian damokidebuli qceviT regulaciebze • qceviTi regulaciebi zemoqmedebs ekonomikur aqtivobebze da Sesabamisad biujetze, da biujeturi regulacia SesaZlebelia iyos efeqturi mxolod im SemTxvevaSi Tu is zemoqmedebas axdens qcevaze • gansxvaveba aris intervenciis strategiaSi aseT SemTxvevaSi • aSS –Si 1980 iani wlebidan gamoCnda biujeturi regulaciebi arsenali • aris molodini, rom iqneba seriozuli cvlileba am mimarTulebiT Tumca P4P moqmedebaSia maregulirebeli midgomebi • licenzireba • serTificireba • akreditacia Llicenzireba mTavrobis mier marTuli savaldebulo programa, romelic moiTxovs, rom: samedicino dawesebulebebi akmayofilebdnen minimalur samoqmedo standartebs serTificireba nebayoflobiTi samTavrobo an arasamTavrobo programa, romelic aRiarebs, rom: samedicino dawesebulebebi akmayofileben garkveul standartebs specializirebul mimarTulebaSi. akreditacia umetesad nebayoflobiTi procesi, romliTac samTavrobo da arasamTavrobo organoebi aniWeben aRiarebas im samedicino dawesebulebebs, romlebic akmayofileben garkveul standartebs, romelic moiTxovs uwyvet struqturul, procesualur da Sedegobriv ganviTarebas. standartebi es aris moTxovnebi, romlebic gansazRvraven Sesrulebis molodinebs struqturis, procesis da Sedegis gaTvalisiwnebiT. unda arsebobdes organizaciaSi, raTa uzrunvelyofili iyos pacientis usafrTxoeba da movlis xarisxi. I. pacientcentruli momsaxureba • pacientis/mosaxleobis (saWiroebebis Seswavla/gaTvaliswineba); • pacientis uflebebis dacva; • eqimis da pacientis urTierTobebis gaumjobeseba (imijis gamosworeba); • pacientis ganaTleba • momxmareblis maqsimaluri CarTva gadawyvetilebis miRebis procesSi II. adeqvaturi xelmisawvdomoba; • geografiuli; • finansuri (bazisuri kalaTa); • xarisxobrivi (adeqvaturi); • Tanasworoba (eTnikuri, genderuli, profesiuli). III. adeqvaturi samecniero codna; • sarwmuno samecniero kvlevebis warmoeba; • statistikuri meTodebis aqtiuri danergva samedicino sazogadoebaSi; • sarwmuno literaturis gamoyeneba; • samecniero mtkicebulebebze dafuZnebiT gadawyvetilebebis miRebis praqtika IV. kompetenturi jandacvis mimwodeblebi; • prediplomuri ganaTleba; • postdiplomuri ganaTleba; • licenzireba, akreditacia (dawesebulebebis); • mimwodebelTa Sefasebis Tvladi kriteriumebis SemuSaveba; • uwyveti samedicino da profesiuli ganaTleba; • dawesebulebebis, medpersonalis optimizacia. V. samedicino da finansuri gadawyvetilebebis gamijvna; • samedicino dawesebulebaTa da med. personalis dafinansebis gamarTuli politikis SemuSaveba; • swori motivaciuri sistemis SemuSaveba; • klinikuri da kliniko-ekonomikuri standartebis Camoyalibeba VI. jandacvis sistemis swori organizacia (efeqtianoba, efeqturoba); • axali struqturuli erTeulis Camoyalibeba • saxelmwifo, naxevrad saxelmwifo Tu decentralizebuli modelebis ganxilva; • multiseqtoraluri kolaboraciis uzrunvelyofa; • mkafiod gansazRvruli pasuxismgeblobebis Camoyalibeba; • samedicino momsaxurebis balansireba pirvelad moereul da mesameul rgolebs Soris; • marTvis informaciuli sitemebi; • adeqvaturi mmarTvelobiTi gundebiT samedicino dawesebulebaTa uzrunvelyofa; • samecniero mtkicebulebebze dafuZnebuli marTvis praqtika xarisxis gaumjobesebis meTodebi modeli I finansuri stimulireba: 1.1 pirdapiri finansuri stimulebi mimwodebels kargi xarisxisTvis 1.2 rogorc saukeTeso mimwodeblis saxalxo aRiareba 1.3 momxmareblis finasuri stimulireba ukeTesi xarisxis arCevisaTvis 1.4 xarisxTan dakavSirebuli aqtivobebis subsidireba modeli #2 seleqtiuri kontraqtireba saukeTeso maCveneblebis mqone mimwodebelTan 2.1 kontraqtiT gansazRvruli ufleba movaleobebi 2.2 Sesrulebis kriteriumebis danergva 2.3 saukeTeso centrebis aRiareba – referens centrebad qceva, seleqtiuri kontraqtireba modeli #3 regulirebis sxva saSualebebi, 3.1 mimwodebelTa qcevis regulacia (licenzireba uwyveti samedicino ganaTlebisa da profesiuli ganviTarebis CarTviT). Tanamedrove klinikuri gaidlainebisa da protokolebis danergva; 3.2 struqturis gaumjobesebis xelSewyoba, dawesebulebaTa gamkacrebuli standartebis da axali kriteriumebis danergviT 3.3 procesis xelSewyoba akreditaciis procesis danergviT gamWvirvaloba sikvdiloba saavadmyofoebis mixedviT saavadmyofoSi Semobrunebis maCvenebeli barZayis motexilobis gaTuleba sakeisro kveTa saavadmyofoebis mixedviT instruqciebi gawerisas Tambaqos sawinaaRmdego kampania saavadmyofoSi didi madloba