What is the operating activity of the company. Performance indicators of inpatient health care institutions

1. Identification and establishment of the causes, factors and conditions for the emergence of group infectious diseases and food poisoning associated with food industry, catering, trade.

(Number of cases of identifying the causes of diseases / Total number of group diseases (poisoning)) x 100 (%%)

Standard value: in 100% of cases, the establishment of causes, factors and conditions.

Positive dynamics: increase in the proportion of cases of group diseases (poisoning) with the establishment of the causes of occurrence.

2. Identification and establishment of causes, factors and conditions of occurrence occupational diseases(at food hygiene enterprises).

(Number of cases of occupational diseases with established cause/ Total number of occupational diseases) x 100 (%%)

Standard value: in 100% of cases, the cause of occupational diseases was established.

Positive dynamics: an increase in the proportion of occupational diseases with an established cause.

3. Complete coverage of construction, reconstruction and operation facilities by the state sanitary and epidemiological supervision.

(Number of objects covered by state sanitary and epidemiological supervision / Total number of objects subject to state sanitary and epidemiological supervision) x 100 (%%)

Standard value: 100% coverage of objects subject to state sanitary and epidemiological supervision.

Positive dynamics: increase in the percentage of coverage of objects by the state sanitary and epidemiological supervision relative to the previous period.

4. Hygienic control over the nutrition of organized groups.

(No. of GCs covered by gig food control / No. of OCs subject to gig food control plan) x 100 (%%)

Standard value: 100% fulfillment of the hygienic control plan for the nutrition of organized groups.

Positive dynamics: increase in the percentage of coverage of organized groups subject to hygienic food control, relative to the previous period.

5. Coverage by preliminary and periodic medical examinations of workers who have contact with food raw materials and food products in the process of their production, storage, transportation and sale.

(Number of persons who passed medical examinations / Number of persons subject to medical examinations) x 100 (%%)

Standard value: 100% of employees must be covered by medical examinations.

Positive dynamics: increase in the proportion of workers covered by medical examinations.

6. The completeness of the application of administrative measures of coercion, adequate to the identified sanitary offenses.

(Number of measures taken / Number of identified sanitary offenses) x 100 (%%)

Standard value: taking action in 100% of cases of detection of sanitary offenses Positive dynamics: increase in the proportion of measures taken to the number of identified sanitary offenses relative to the previous period.

7. The proportion of the number of fines collected to the number of fines imposed.

(Number of fines collected / Number of fines imposed) x 100 (%%)

Standard value: 100% of the fines imposed must be collected.

Positive dynamics: increase in the share of fines collected.

8. The proportion of suspended and closed objects of group III in terms of sanitary and technical condition to the total number of objects of this group.

(Number of suspended and closed objects of group III / Total number of objects of group III) x 100 (%%)

Standard value: 100% of Group III facilities must be suspended or closed.

Positive dynamics: increase in the share of suspended and closed objects of group III compared to the previous period.

The final assessment of the quality of activities should be assessed by a point system. Points are calculated according to special formulas, see Guidelines 5.1.661.-97. "The system for assessing and controlling the quality of the activities of the center and structural divisions centers".

To study the relationship between the performance indicators of the Central State Sanitary and Epidemiological Service and their structural divisions, the sequence of their determination, as well as the calculation of specific indicators, a computer model of data processing can be used. Data processing is carried out by methods of evaluation-performance, efficiency and quality based on the Clarion language. computer model contains schemes-links of indicators of effectiveness, efficiency and quality, schemes, algorithms for the sequence of determining these indicators and formulas for their calculation. The tested model of computer assessment is designed for direct use by specialists of sanitary and epidemiological institutions in the mode of an interactive "menu".

  1. Vankhanen V.D., Lebedeva E.A. Guide to practical exercises in food hygiene. M.: Medicine, 1987. pp. 7-25.
  2. Naval and radiation hygiene. In 2 volumes. T.1. - St. Petersburg: "LIO Editor", 1998. - pp. 340 -341.
  3. Koshelev N.F., Mikhailov V.P., Lopatin S.A. Troop food hygiene. Tutorial Part II. Organization of food control. - St. Petersburg: Military Medical Academy, 1993. - 259 pages.
  4. Knopov M.Sh. Sanitary and hygienic service at the front and in the rear / Hygiene and sanitation / N 4. 2000. pp. 70-72.

5. Nushtaev I.A. From the history of the development of public hygiene in Russia / Hygiene and sanitation / N 4. 1999. pp. 76-78.

  1. Evaluation of the quality of activities of divisions of district and regional centers of state sanitary and epidemiological supervision in modern conditions. / Kutsenko G.I., Petruchuk O.E., Manvelyan L.V., Danialova D.Ch. et al. / Hygiene and sanitation - 1998 - N 1. pp. 55-56.
  2. Decree of the Government of the Russian Federation of 24.07.2000. No. 554. "Regulations on the State Sanitary and Epidemiological Service Russian Federation».
  3. Decree of the Government of the Russian Federation of December 21, 2000. No. 987 "On state supervision and control in the field of ensuring the quality and safety of food products".
  4. Accreditation system for testing laboratories (centers) of the State Sanitary and Epidemiological Service of the Russian Federation. - Moscow. 1997. 46pp.
  5. The system for assessing and monitoring the quality of the activities of the centers of state sanitary and epidemiological supervision and structural divisions of the centers: Methodological instructions. - M.: information and publishing center

Ministry of Health of Russia, 1997. - 47.

  1. Federal Law of the Russian Federation "On the sanitary and epidemiological well-being of the population" dated 30.03.1999. No. 52-FZ.
  2. Federal law of the Russian Federation "On the quality and safety of food products" dated 02.01.2000. No. 29-FZ

M.V. Dubchenko, R.V. Bannikova Sanitary-epidemiological service and public health in the North. Arkhangelsk 1998 P.237.

· BASIC DEFINITIONS -

· SANITARY SUPERVISION FOR FOOD. PURPOSE, OBJECTIVES, OBJECTS OF CONTROL

· BRIEF HISTORICAL SUMMARY OF FORMATION AND DEVELOPMENT OF SANITARY SUPERVISION

STRUCTURE OF THE STATE SANITARY AND EPIDEMIOLOGICAL SERVICE

RIGHTS AND OBLIGATIONS OF OFFICIALS OF THE SANITARY AND EPIDEMIOLOGICAL SERVICE FOR THE SECTION OF FOOD

· MAIN ACTIVITIES OF A FOOD HYGIENE DOCTOR.

· PLANNING, FORMS AND METHODS OF WORK OF THE INSTITUTIONS OF THE STATE SANEPIDED SERVICE

· PROFESSIONALLY - DEONTOLOGICAL PRINCIPLES OF THE ACTIVITY OF A SANITARY DOCTOR

DOI: 10.21045/2071-5021-2016-52-6-2
Zubko A.V., Sabgaida T.P.
Federal State Budgetary Institution "Central Research Institute for the Organization and Informatization of Healthcare" of the Ministry of Health of the Russian Federation, Moscow

VASCULAR SURGERY IN HOSPITALS OF DIFFERENT LEVELS
Zubko A.V., Sabgayda T.P.
Federal Research Institute for Health Organization and Informatics of Ministry of Health of the Russian Federation, Moscow

Contact Information : Alexander Zubko, This e-mail address is being protected from spambots. You must have Javascript enabled in your browser to view it.

Contacts : Alexander V. Zubko, e-mail: This e-mail address is being protected from spambots. You must have Javascript enabled in your browser to view it.

Summary. Departments of X-ray surgical methods of diagnosis and treatment were created not only at third-level medical organizations, which could affect the quality of this high-tech care.

Target . To test this hypothesis, we analyzed data on operational activity in vascular reconstruction and its results in medical organizations of various levels.

Methods . The analysis was carried out on the basis of data from the collections of the Scientific Center for Cardiovascular Surgery. A.N. Bakulev on interventions in patients with occlusive diseases of the aorta and arteries of the lower extremities in 2010-2014. Data from 188 vascular departments were divided into groups in two ways: by belonging to medical organizations of the first, second or third levels and by the average annual number of vascular reconstructions performed.

Work results . At the second level of delivery medical care 51.0% of vascular reconstruction interventions are performed, the first one - 36.2%, the third one - 12.7%. The frequency of amputations after vascular reconstructions and reoperations increases with the increase in the number of interventions performed, from 0.6% and 1.3%, respectively, in organizations with an average annual number of reconstructions of less than 20 to 1.9% and 2.5% in organizations with an average annual number of renovations over 100, as well as from 0.3% at the third level to 1.3% at the second and first levels in 2014.

conclusions . The redistribution of patients with surgical vascular diseases among organizations providing medical care at various levels does not correspond to the current paradigm of a three-level organization of medical care. With an increase in the flow of patients (an increase in surgical activity), the proportion of repeated operations, including those ending in amputations, increases proportionally. Resource support of second-level medical organizations is not enough to effective treatment patients with advanced stages of surgical vascular diseases. In order to avoid an increase in the frequency of amputations of the lower extremities, measures are required to stimulate third-level medical institutions to increase the proportion of interventions for vascular reconstruction.

Keywords : treatment of surgical vascular diseases; the frequency of vessel reconstructions that ended in amputation; the frequency of repeated vascular reconstructions; departments of X-ray surgical methods of diagnostics and treatment.

abstract. Departments of interventional radiology diagnostics and treatment were set up not only at the third level hospitals, which could have affected quality of this high-tech medical care.

Purpose . To test this hypothesis, we analyzed data on surgical activities for vascular reconstruction and its results in hospitals of different levels.

methods . Analysis was based on the data of the A.N. Bakoulev Scientific Center for Cardiovascular Surgery on interventions in patients with occlusive diseases of aorta and arteries of lower extremities in 2010-2014.

Data from 188 vascular departments were divided into groups as follows: by the level of care delivery, i.d. hospitals of the first, second or third levels and by the average annual number of vascular reconstructions performed.

results . 51.0% of interventions for vascular reconstruction are implemented at the second level of care delivery, 36.2% - at the first and 12.7% at the third level of care delivery. Frequency of amputations after the reconstruction and repeat operations increase along with the increasing number of interventions performed: increase from 0.6% and 1.3% respectively in hospitals with the average annual number of reconstructions under 20 and to 1.9% and 2.5% in hospitals with the average annual number of reconstructions over 100; from 0.3% in the third level hospitals to 1.3% in hospitals of the first and second levels of care delivery in 2014.

Conclusions . Reallocation of patients with surgical vascular diseases across hospitals of different levels does not correspond to the current paradigm of the three-level care organization. The share of repeat operations (including amputations) proportionally increases along with the increasing patient flow (surgical activity). Resource provision of the second level hospitals is not sufficient to effectively treat patients with late stages of surgical vascular diseases. Measures to incentivize the third-level hospitals to increase the share of interventions for vascular reconstruction are required to avoid growth of the lower limb amputations’ frequency.

keywords : treatment of surgical vascular diseases; frequency of vascular reconstructions ended by amputation; frequency of repeat angioplasty; departments of interventional radiology diagnostics and treatment.

Vascular surgery, including minimally invasive X-ray endovascular treatment, is a specialized high-tech medical care. In the surgical treatment of occlusive diseases of the aorta and arteries of the lower extremities, the most high-tech method is X-ray surgery. Unlike open surgeries, these interventions have lower mortality and better prognosis in postoperative rehabilitation of patients with surgical vascular diseases. At the same time, X-ray surgical interventions are strictly limited. clinical picture: in advanced cases of the disease, such interventions are not possible. X-ray endovascular surgery as a profitable alternative to open surgery has recently been successfully developed all over the world, while the success of endovascular interventions is achieved in the vast majority of cases, including due to a significant increase in the effectiveness of drug treatment of obliterating vascular diseases.

In recent years, the number of specialized and multidisciplinary clinics has been growing, which include departments of X-ray surgical methods of diagnosis and treatment.

In 2010, there were 175 centers (departments) of X-ray endovascular diagnostics and treatment in the Russian Federation, in 2014 - 273, and in 2015 - 299. These centers (departments) are created not only at third-level medical organizations (medical organizations providing mainly specialized medical care, including high-tech), but also at the first level (district, district and city hospitals providing primary health care, including including specialized), and the second (diversified hospitals, medical organizations that have specialized inter-municipal or inter-district departments in their structure).

The Profile Commission for Cardiovascular Surgery under the Chief Specialist of the Ministry of Health of the Russian Federation and the Russian Scientific Society of Specialists in X-ray Endovascular Diagnosis and Treatment collect information on the problem of cardiovascular and endovascular surgery, analyze it and publish the results in statistical collections. Information is collected on a voluntary basis, and not all centers (departments) of X-ray endovascular diagnostics and treatment provide this information. Thus, in 2014, 237 out of 273 institutions provided information. Analysis surgical treatment cardiovascular diseases is carried out quite actively both on the basis of this information and on the basis of statistical reporting data of the Ministry of Health of Russia. At the same time, there is practically no detailed analysis of the treatment of patients with occlusive diseases of the aorta and arteries of the lower extremities, although vascular reconstruction is one of the activities of vascular centers.

To test this hypothesis, that the quality of this type of high-tech medical care depends on the level medical organization, we analyzed data on operational activity in vascular reconstruction and its results in medical organizations of various levels.

Research methods

The analysis was carried out on the basis of data from the collections of the Scientific Center for Cardiovascular Surgery. A.N. Bakulev on interventions in patients with occlusive diseases of the aorta and arteries of the lower extremities in 2010-2014. In total, data from 188 vascular centers (departments) were analyzed, which were divided into groups in two ways: by belonging to medical organizations of the first, second or third levels and by the average annual number of vascular reconstructions. The groups were compared by the share among all reconstructions of X-ray surgical procedures on the aorta and arteries of the lower extremities (as requiring the use of the most complex technologies), by the proportion of repeated reconstructions and reconstructions that ended in amputation (as indicators of the quality of surgical care), as well as by the dynamics of these indicators.

The data were copied from the collections and a database was formed in the Microsoft Office Excel 2003 program, with the help of which the information was analyzed.

The frequencies of repeated reconstructions and reconstructions that ended in amputation in different groups of organizations were compared by the method of four-field tables using the χ-square test, the probability of differing proportions was calculated, which was considered significant with the error value.<0,05. Расчеты проводили в программе EPI INFO, Version 3 (EPO CDC, 1988).

Pearson's correlation coefficients and their errors were calculated using the STATISTICA 6.1 program to identify the relationship between the variables "Total number of vascular reconstructions", "Percentage of repeated reconstructions" and "Percentage of amputations after reconstructions" in organizations of different levels.

results

An analysis of operational activity in vascular centers (departments) of medical institutions of various levels for 2010-2014 showed that about a sixth of vascular reconstructions (12.7%) are performed at the third (federal) level, half at the second level of medical care, more thirds - at the first level (Table 1).

Table 1

Average values ​​of indicators of the volume of surgical care and its quality in vascular departments of different levels for the period 2010-2014, the contribution of vascular centers of different levels to the total number of reconstructions

Average number of reconstructions (contribution) Share of RC procedures on the aorta and arteries of the lower extremities, % (contribution) Repeated reconstructions, % (contribution) Share of reconstructions ending in amputation, % (contribution)
First N=75 358.2±40.5
(36,2%) 		16.2±2.0
(32,1%) 		1.7±0.28
(27,5%) 		1.4±0.22
(35,3%)
Second N=87 434.7±40.2
(51,0%) 		18.3±2.0
(51,0%) 		2.5±0.46
(57,8%) 		1.7±0.21
(59,3%)
Third N=26 362.9±53.8
(12,7%) 		24.4±4.54
(17,0%) 		2.5±0.77
(14,7%) 		0.6±0.22
(5,4%)
Total N=188 394.2±25.7
(100%) 		18.3±1.4
(100%) 		2.2±0.26
(100%) 		1.4±0.14
(100%)

X-ray surgery

The distribution of the frequency of the most high-tech methods (X-ray surgical interventions) is somewhat different: at the third level, the proportion of such operations among all reconstructions is greater than in the vascular centers of the first and second levels, as a result of which the contribution of federal vascular centers to the performance of X-ray endovascular procedures on the aorta and arteries of the lower extremities is Russian citizens somewhat more than in the performance of all reconstructions of blood vessels. It can be noted that the greater the proportion of X-ray surgical interventions among all vascular reconstruction procedures, the lower the proportion of reconstructions that ended in amputation (correlation coefficient -0.15, .=0.037).

The frequency of repeated reconstructions in angiosurgical departments is lower at the first level, while the contribution of organizations of this level to the total volume of repeated vessel reconstructions is less than their contribution to the total number of vessel reconstructions. At the same time, there is no difference in this indicator in the vascular departments of organizations of the second and third levels. The frequency of vascular reconstructions that ended in limb amputation is the lowest at the third level. At the second level, the frequency of amputations is higher than at the first level by 20% and more than at the second level by 2.7 times.

During the analyzed period, the number of vascular reconstruction surgeries among the Russian population increased from 11.6 thousand to 18.0 thousand. of this type of surgical care has stabilized, while in the angiosurgical departments of the first and second levels, a steady increase in the number of vascular reconstruction operations is observed (Fig. 1).


Rice. 1. The annual share of vascular reconstruction operations of their total number for the period 2010-2014 in vascular departments of different levels (% of the amount)

Among all vascular reconstruction surgeries over the analyzed period, the proportion of the most high-tech X-ray surgical procedures on the aorta and arteries of the lower extremities is growing, but in the vascular departments of the first level there is a constant increase in this proportion, while in organizations of the second and third levels in 2014 it is observed to decrease (Fig. .2).



Rice. 2. The proportion of X-ray surgical procedures on the aorta and arteries of the lower extremities for the period 2010-2014 in vascular departments of different levels (%)

The frequency of repeated reconstructions of vessels in the period 2010-2014 does not change linearly (Fig. 3). In the last year of the analysis, it decreases in the vascular departments of all levels. In institutions of the second and third levels, the frequency of repeated reconstructions of blood vessels in 2014 is less than in 2010, in institutions of the first level it is higher.



Rice. 3. The frequency of repeated reconstructions of vessels in the period 2010-2014 in vascular departments of different levels (%)

Interestingly, the type of curves reflecting the dynamics of the frequency of repeated vascular reconstructions and the dynamics of the frequency of reconstructions that ended in amputation (Fig. 4) is similar in medical organizations of the second and third levels, while in the vascular departments of the first level, the type of compared curves is different. In 2014, the proportion of reconstructions ending in amputation in the first level medical institutions was equal to that of the second level (1.3%), although before that, most of the unsuccessful interventions were observed at the second level. The frequency of limb amputations in the vascular centers of third-level institutions was the lowest for the entire observation period and in 2014 amounted to 0.3%. In federal vascular centers, the largest proportion of reconstructions that ended in amputation was 1.08% in 2011, while the smallest proportion in first-level organizations was 1.13% in the same year, in second-level institutions - 1.26% in 2014 .



Rice. 4. The frequency of vascular reconstructions that ended in amputation in the period 2010-2014 in vascular departments of different levels (%)

For organizations of the first and second levels, a positive correlation was found between the indicators of the quality of surgical care among themselves: the proportion of repeated reconstructions of vessels and reconstructions that ended in amputation (Table 2). The number of all interventions for vascular reconstruction correlates with the proportion of repeated reconstructions in first-level organizations. At the second level, a positive correlation was found between the proportion of amputations and total number reconstructions. At these levels, the expected relationship between the number of interventions and the second indicator of the quality of surgical care (with the number of reconstructions that ended in amputation in the organizations of the first level and with the number of repeated reconstructions in the organizations of the second level) was not revealed. As for the organizations of the third level, no statistically significant correlation of the analyzed indicators was revealed for them.

Considering the increase in the number of vascular reconstruction operations in the vascular departments of organizations of the first and second levels, with a stable number of them in organizations of the third level, the revealed correlation of the quality of surgical care with the total volume of interventions may be associated with a decrease in the quality of work due to overload of surgeons and/or restrictions in consumables for specialized operations in organizations of the first and second levels.

table 2

Correlation coefficients of quality indicators of surgical care in vascular departments of different levels among themselves and with the total number of reconstructions over the period

Levels of Surgical Care ()
Total renovations and repeated reconstructions and
repeated reconstructions reconstructions ending in amputation
First N=75 0,30* (p=0.008) 0,07 (p=0.565) 0,25* (p=0.029)
Second N=87 0,05 (p=0.640) 0,42* (p=0.0001) 0,27* (p=0.010)
Third N=26 0,13 (p=0.512) 0,09 (p=0.665) 0,38 (p=0.055)

p>0.05)

To test this hypothesis, we divided all vascular departments (centers) into 4 groups depending on the number of interventions for vascular reconstruction. This division does not correlate in any way with the division of medical organizations according to the levels of medical care. Thus, among 34 organizations in which less than 20 surgical interventions were performed per year in patients with occlusions of the aorta and peripheral arteries, there were 5 organizations of the third level; among 57 organizations with an average annual number of vessel reconstructions exceeding 100, the number of organizations of the third level is 8, and the number of organizations of the first level is 18. Table 3 shows that the frequency of amputations after vascular reconstructions and reoperations increases as the number of interventions increases. Pairwise differences in the proportion of reconstructions that ended in amputation and the proportion of repeated reconstructions between the selected groups of medical organizations are statistically significant (.<0,05), за исключением групп с операционной активностью от 60 до 100 и более 100 реконструкций в год.

Table 3

Average values ​​of indicators of the volume of surgical care and its quality in groups of vascular departments with different operational activities for the period 2010-2014

If, when calculating, from the group with the highest operational activity, third-level organizations are excluded, then the proportion of repeated reconstructions will not change (2.5%), and the proportion of reconstructions that ended in amputation increases to 2.2%. Statistically significant (.=0.001) is the difference in the proportion of reconstructions that ended in amputation between the two groups of organizations with high operational activity (from 60 to 100 and more than 100).

Table 4 shows the results of a correlation analysis of the quality of surgical care for selected groups of organizations. A positive correlation between the proportion of repeated reconstructions and reconstructions that ended in amputation was found for organizations with an average annual number of reconstructions from 20 to 100. If the number of vessel reconstructions is less than 20 or more than 100 per year, then there is no relationship between the number of amputations after reconstructions and the number of repeated reconstructions.

Table 4

Correlation coefficients of quality indicators of surgical care in vascular departments with different operational activity among themselves and with the total number of reconstructions over the period

Average annual number of operations Correlation coefficients of indicators: (correlation coefficient errors)
Total renovations and repeated reconstructions and
repeated reconstructions reconstructions ending in amputation reconstructions ending in amputation
Less than 20 N=34 0,14 (p=0.427) -0,13 (p=0.469) 0,08 (p=0.668)
20-60 N=59 0,25 (p=0.060) 0,32* (p=0.013) 0,40* (p=0.002)
60-100N=38 0,46* (p=0.003) 0,11 (p=0.526) 0,44* (p=0.005)
More than 100 N=57 0,04 (p=0.740) 0,12 (p=0.373) -0,01 (p=0.930)

* - significantly different from zero ( p>0.05)

A statistically significant correlation between the number of reconstructions and the proportion of reconstructions ending in amputation was found only for the group of organizations where the average annual number of reconstructions is not high (20-60). If the number of reconstructions is more than 60 per year, then there is no connection between their number and the proportion of reconstructions that ended in amputation.

Positive correlations were revealed, the number of reconstructions with the share of repeated reconstructions for organizations with an average annual number of reconstructions from 60 to 100.

Discussion

The distribution of the number of vascular reconstructions by groups of medical institutions at different levels does not correspond to the ideology of a three-level medical care, when high-tech operations should be performed at the third level. According to federal law dated November 21, 2011 N 323-FZ "On the basics of protecting the health of citizens in the Russian Federation", the reconstruction of blood vessels at the first and second levels should be carried out only in emergency cases, elective operations should be carried out in medical organizations of the third level, i.e. in the conditions of federal vascular centers with appropriate equipment. In practice, the largest number of interventions for vascular reconstruction is carried out at the second level of medical care, and the average number of reconstructions performed at the first and third levels is close.

A higher percentage of interventions using the most sophisticated equipment, X-ray surgery, at the third level compared to the first and second levels can be explained by the location of federal vascular centers in large cities, where the primary detection rate, as well as the availability of endovascular treatment of occlusive diseases of the aorta and arteries of the lower extremities is higher, than in other cities. A lower proportion of re-reconstructions in the angiosurgical departments of first-level organizations indicates a tendency to send patients with severe forms of diseases from the first level to a higher level of medical care. Vessel reconstructions that ended in amputation of the limbs most often indicate the inadequate quality of surgical care. The lowest frequency of amputations is observed at the third level, which indicates a better supply of federal centers and a higher qualification of surgeons working there. The equipment of the vascular centers of the first level does not allow performing high-tech operations on vessels with proper quality, however, the proportion of amputations in the second level organizations is higher than in the first level organizations, which can be explained by more severe forms of surgical vascular diseases in the second level organizations. The almost threefold excess of amputations at the second level compared with the third level cannot be explained only by the need for emergency operations in case of serious illnesses. Apparently, the vascular departments of the second level are insufficiently equipped with appropriate instruments, suture material and prostheses. Leading experts in the field of vascular surgery note the limitations of the surgical activity of the departments of cardiac and vascular surgery, associated with incomplete funding and limited purchases of consumables.

The calculation of the annual share of operations from their total number for five years for each level made it possible to clearly demonstrate a decrease in the flow of patients with surgical vascular diseases hospitalized at the third level, while the number of patients with cardiac surgery is growing. The main burden falls on second-level organizations that do not have sufficient capacity, which leads to an increase in the number of limb amputations among the population, which could have been avoided by angioplasty in federal vascular centers. The steady growth in the share of the most high-tech vascular reconstruction procedures in the vascular departments of the first level means that high-tech medical care is being introduced more widely there.

In 2014, the frequency of repeated vascular reconstructions in vascular departments of all levels is decreasing, which may indicate an increase in the quality of vascular reconstruction operations as a result of the accumulation of surgical experience against the background of improved means conservative treatment and prevention of complications. This conclusion is confirmed by literature data: the dependence of the effectiveness of cardiovascular interventions on the accumulated experience of surgeons was revealed.

The frequency of vascular reconstructions ending in amputations is the lowest in medical institutions of the third level. At the same time, the share of vascular reconstruction operations in the total number of operations performed in third-level medical institutions is decreasing, while in medical institutions of the first and second levels this frequency is growing, which makes it possible to predict an increase in the disability of the population.

The results of the correlation analysis led to the conclusion that in medical organizations of the first and second levels, with an increase in the total number of operations, the quality of surgical treatment decreases. In medical organizations of the first level, with an increase in the total number of vascular reconstruction operations, the frequency of repeated reconstructions increases, but the frequency of reconstructions ending in amputation does not change. This can be explained by the fact that patients with the most severe course diseases, often requiring amputation, from the first level of care to the second or third. In organizations of the second level, with an increase in the total number of operations, there is a tendency for an increase in complications (clinical conditions) that entail amputation. At the same time, there is a tendency to avoid repeated reconstructions. The absence of a correlation between the indicators of the quality of surgical care among themselves and with the total volume of operations performed at the third level reflects the fact that amputations there have little to do with the quality of surgical care, but are determined by the stage of the disease.

The presence of a correlation between the proportion of reconstructions ending in amputation and the total number of reconstructions only for a group of organizations with a small number of reconstructions (20-60) can be explained by the fact that it is under such conditions that an increase in the level of qualification of individual surgeons can occur with a sufficient number of interventions performed on vessels. With a greater number of reconstructions, limitations in the equipment of consumables and prostheses are already affecting. The absence of a correlation between the number of amputations after reconstructions and the number of repeated reconstructions in organizations with less than 20 vessel reconstructions is associated with the difficulty of identifying correlations when analyzing small values. The lack of correlation between the quality of surgical care variables in organizations with more than 100 reconstructions per year can be explained by the fact that, with a large flow of patients, the high rate of consumption of medical devices for vascular operations and, accordingly, interruptions in their supply, lead to the choice of amputations instead of repeated reconstructions in case of ineffective primary reconstructions of vessels. Such a tactic is not in line with the recommendation of the European Consensus Document that reconstructive interventions should be undertaken with a 25% chance of saving at least a year of the patient's functional limb.

conclusions

The redistribution of patients with surgical vascular diseases among organizations providing medical care at various levels does not correspond to the current paradigm of a three-level organization of medical care.

With an increase in the flow of patients (an increase in surgical activity), the proportion of repeated operations, including those ending in amputations, increases proportionally.

Resource provision of medical organizations of the second level is not enough for effective treatment of patients with advanced stages of surgical vascular diseases. The direction of such patients there leads to an increase in the number of amputations and an increase in the disability of the population.

In order to avoid an increase in the frequency of amputations of the lower extremities, additional measures are required to stimulate third-level medical institutions to increase the proportion of interventions for vascular reconstruction.

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  7. Vertkina N., Khamitov F., Lisitsyn Yu. Clinical and economic analysis of the treatment of patients obliterating atherosclerosis lower extremities depending on the method of therapy. Doctor 2007; (9): 69-72.
  8. Katelnitsky I.I., Livadnyaya E.S. Methods of treatment of patients with obliterating atherosclerosis of arteries of the lower extremities in critical ischemia. Contemporary Issues science and education[Electronic scientific journal] 2014; (3): 463. URL: http://www.science-education.ru/ru/article/view?id=13206 (date of access: 19.09.2016).
  9. On current issues in the fight against cardiovascular diseases. Analytical Bulletin[Electronic scientific journal] 2015; 597(44): 1-108. URL: http://www.budgetrf.ru/Publications/Magazines/VestnikSF/2015/44_597/VSF_NEW_44_597.pdf(Accessed 6.09.2016)
  10. Podzolkov V.P., Alekyan B.G., Kokshenev I.V., Cheban V.N. Reoperations after correction of congenital heart defects. Moscow: "NTSSSH im. AN Bakuleva RAMS"; 2013. 364 p.
  11. Saveliev V.S., Koshkin V.M., Kunizhev A.S. Critical ischemia as a result of inadequate treatment of patients with chronic obliterating diseases of the arteries of the lower extremities at the outpatient stage. Angiology and Vascular Surgery 2004; 10(1): 6-10.

References

  1. Bogachevskaya S.A., Bogachevskiy A.N., Bondar V.Yu. [ Three-year contribution of the Federal centers for cardiovascular surgery to the development of high-tech medical care for patients with cardiovascular diseases in Russia]. Sotsial "nye aspekty zdorov" ya naseleniya 2016; 47(1). Available from: (in English).
  2. Bokeriya L.A., Alekyan B.G. Rentgenendovaskulyarnaya diagnostika i lechenie zabolevaniy serdtsa i sosudov v Rossiyskoy Federatsii - 2010 god. . Moscow: NTsSSKh im. A.N. Bakuleva RAMN; 2011. 142 p. (In Russian).
  3. Bokeriya L.A., Alekyan B.G. Rentgenendovaskulyarnaya diagnostika i lechenie zabolevaniy serdtsa i sosudov v Rossiyskoy Federatsii - 2015. . Moscow: NTsSSKh im. A.N. Bakuleva; 2016. 222 p. (In Russian).
  4. Bokeriya L.A., Gudkova R.G. Serdechno-susudistaya khirurgiya-2012. Bolezni i vrozhdennye anomaly sistemy krovoobrashcheniya. . Moscow: NTsSSKh im. A.N. Bakuleva; 2013. 210 p. (In Russian).
  5. Bokeriya L.A., Gudkova R.G. Serdechno-sosudistaya khirurgiya-2013. Bolezni i vrozhdennye anomaly sistemy krovoobrashcheniya. . Moscow: NTsSSKh im. A.N. Bakuleva; 2014. 220 p. (In Russian).
  6. Bokeriya L.A., Gudkova R.G. Serdechno-sosudistaya khirurgiya-2014. Bolezni i vrozhdennye anomaly sistemy krovoobrashcheniya. . Moscow: NTsSSKh im. A.N. Bakuleva; 2015. 226 p. (In Russian).
  7. Vertkina N., Khamitov F., Lisitsyn Yu. Kliniko-ekonomicheskiy analiz lecheniya bol "nykh obliteriruyushchim aterosklerozom nizhnikh konechnostey v zavisimosti ot metoda terapii. . Vrach 2007; (9): 69-72. (In Russian).
  8. Katel "nitskiy I.I., Livadnyaya E.S. Methody lecheniya bol" nykh obliteriruyushchim aterosklerozom arteriy nizhnikh konechnostey pri kriticheskoy ishemii. . Modern problemy nauki i obrazovaniya 2014; (3): 463. Available from: http://www.science-education.ru/ru/article/view?id=13206 (in Russian).
  9. Ob aktual "nykh problemakh bor" by s serdechno-sosudistymi zabolevaniyami. . Analiticheskiy vestnik 2015; 44(597): 1-108. Available from: http://www.budgetrf.ru/Publications/Magazines/VestnikSF/2015/44_597/VSF_NEW_44_597.pdf (in Russian).
  10. Podzolkov V.P., Alekyan B.G., Kokshenev I.V., Cheban V.N. Povtornye operatsii posle korrektsii vrozhdennykh porokov serdtsa. . Moscow: NTsSSKh im. A.N. Bakuleva RAMN; 2013. 364 p. (In Russian).
  11. Savel "ev V.S., Koshkin V.M., Kunizhev A.S. Kriticheskaya ishemiya kak sledstvie neadekvatnogo lecheniya bol" nykh khronicheskimi obliteriruyushchimi zabolevaniyami arteriy nizhnikh konechnostey on ambulatornom etape. . Angiologiya i sosudistaya khirurgiya 2004; 10(1): 6-10. (In Russian).

Date of receipt: 10.10.2016.


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The report on the activities of the hospital (annual) is compiled by hospital treatment and preventive organizations of all profiles for adults and children and submitted to the higher health authority, the Ministry of Health and further - the Ministry of Statistics and Analysis - within the established time limits.

The structure of the "Report on the activities of the hospital" (form No. 14):

Passport part

Section 1. The composition of patients in the hospital and the outcomes of their treatment

For effective management of the work of the hospital, it is necessary to analyze the indicators characterizing the quality of care for hospitalized patients.

The composition of patients treated in the hospital

The average duration of treatment of a patient in a hospital

Mortality in certain diseases

Daily lethality

The structure of deceased patients in the hospital

The indicator of coincidence of clinical and pathoanatomical diagnoses (calculated according to the data of the pathoanatomical department)

Section 2. The composition of sick newborns transferred to other hospitals at the age of 0-6 days and the outcomes of their treatment

Section 3. Beds and their use

The indicators of the use of the bed fund are very important for characterizing the volume of work of the hospital, the organizational aspects of work, the efficiency of the use of the bed fund and are necessary for calculating the economic indicators of the hospital. The indicators of the use of the bed fund are calculated on the basis of the data in the table of section 3 of the Report on the activities of the hospital.

Average number of bed days per year (average annual bed occupancy per year)

Average length of stay of a patient in a bed (average duration of one hospitalization)

Turnover, beds (hospital bed function)

Hospital mortality

Section 4. Surgical work of the hospital

Surgical activity

Lethality of operated patients (postoperative lethality)

The structure of surgical interventions

The frequency of postoperative complications

Indicators of emergency surgical care:

Late delivery of patients to the hospital

The structure of patients delivered according to emergency indications

The proportion of operated patients for emergency indications

Mortality of patients delivered for emergency indications

When evaluating emergency surgical care, the rates of postoperative complications are also analyzed, taking into account the timing of delivery to the hospital and the type of surgical pathology.



Analysis of the activities of the hospital according to the annual report is carried out in the following sections:

Use of beds

The quality of medical care in the hospital

Surgical work in the hospital

Emergency surgery in the hospital

Indicators- see question 73.

Report of medical and preventive organizations (form 30), structure. Key performance indicators. The method of their calculation.

The main reporting form reflecting the activities of a medical organization is "Report of the medical and preventive organization" (f. 30). This form is compiled by medical and preventive organizations of all profiles for adults and children and submitted to the higher health authority, the Ministry of Health and further to the Ministry of Statistics and Analysis within the established time limits.

The report contains the following sections:

Passport section.

On the left side of the title page, the name of the reporting and higher organizations, the management body, the form of ownership and the address of the medical and preventive organization are indicated. In the right part - the order of presentation of the reporting form.

Section 1. Information about the subdivisions, facilities of the medical and preventive organization.

This section indicates: the names of departments (offices), mobile units, other units that are part of the medical organization. Opposite the name of the department, cabinet, their number is indicated. Data are provided on the work of day hospitals and a hospital at home, as well as on the intensive care unit and the department of emergency and planned advisory care. At the end of the section, the capacity of the polyclinic is shown, expressed as the number of visits per shift.

The operating activity of an enterprise is the main activity for which it was created. The specifics of operating activities depend on the industry in which the company operates. The main types of operating activities of the organization are mainly commercial, trade and industrial relations. Enterprises can also engage in additional activities, but they will already be secondary (for example, financial or investment).

The operational activity of the enterprise is a priority, therefore, secondary activities can only be of a supporting nature. Unlike investment or financial, operating activities are focused on the consumer market of goods produced directly by the enterprise, require significant labor costs, frequent regular business operations.

Operational activity is the goal of the entire life of the enterprise. The profit received from the implementation of operating activities has the most significant percentage in the composition of the total profit.

Operational Analysis

To control the implementation of operational activities, one of the effective methods- operational analysis. The main task of operational analysis is to control the costs of production, output, the volume of production that corresponds to the costs, the ratio of profit to.

In addition, when conducting an operational analysis, the following points should be considered:

What is the availability of reverse capital should be in the enterprise;

How to mobilize available funds;

How to use the effect of financial leverage;

What is more profitable - rent or purchase of means of production;

Does it make sense to sell products at a price below cost;

If you change the volume of sales, how will this affect profits.

Operational analysis is necessary to find the most profitable costs for the enterprise. It allocates costs to:

Variables are the costs of materials and raw materials for production, the wages of workers who work in the main production, marketing costs. The lower the variable costs of the enterprise, the greater the profit;

Permanent - these are the costs of maintaining buildings and structures, depreciation deductions, the salary of the administrative corps;

Direct - refer directly to the output;

Indirect - these are the costs of energy resources for auxiliary production, the salary of maintenance personnel;

Relevant - depend on management decisions;

Irrelevant - these costs can be adjusted in the production capabilities of the enterprise.

Any useful activity is associated with the processing of something. For example, the processing of information on the stock exchange, in publishing or advertising. When providing services (hotel, hairdresser, tourism, etc.), offers are involved in the processing process. Processing operations also take place in the structural (functional) divisions of the enterprise, for example, in the planning department, marketing, personnel, etc.

Modern manufacturing processes are characterized by splicing and interweaving of the main, auxiliary and service processes, while the last two are given an increasing place in the overall production cycle. This is due to the backlog of mechanization and automation of production maintenance in comparison with the equipment of the main production processes. Under these conditions, it becomes more and more necessary to regulate the technology and organization of the implementation of not only the main, but also auxiliary and service processes of production.

The basis of operational management is the management of operating systems. An operating system is a system that uses operating resources to transform an "input" into an "output" product.

An "input" can be a raw material, a customer, or a finished product received from another operating system, or a customer (in a service industry) that needs service.

Operating activities - is the activity that is carried out within the operating system with the aim of creating any utility by converting inputs (resources of all kinds) into outputs (finished goods and services).

The operating function includes the activities that result in the production of products and services supplied by the organization to an external consumer. The function of "operations" is performed by all organizations without exception, otherwise they simply cannot exist.

The essence of the operational function lies in the process of conversion (transformation, transformation), that is, in a sequential series of events during which resources are converted into finished products or services. Schematically, this phenomenon can be conveyed simply: the costs of transformation results.

Distinguish two main types of conversion. The first, known as analytical, involves the transformation of a raw material into one or more distinct products that may or may not resemble the original resource in form and function. Another type of conversion, which is known as synthetic, it is planned to create a single type of product based on the use of a large number of initial materials.

In this way, operating activities is the process of converting inputs into outputs. Operating system inputs include:

1) objects of operational activity, to which the efforts of the system are directed in the process of transformation: a) material resources; b) clients; c) property of clients;

2) means of operating activities;

3) staff.

Part operating system outputs relate:

1) basic: a) finished products; b) a client whose state has been changed; c) client property that has been changed

2) secondary: a) material; b) energy; c) information.

The composition of fixed resources as input factors for operating activities

Production decisions are made in the context of the overall functioning of the enterprise, depending on its place and role in the market and the adopted strategy.

The strategy is based on the mission of the enterprise in the market and reflects how the enterprise plans to use all its resources and functions in order to achieve a competitive advantage.

The operating strategy determines the way and level of use of production capacity, contributing to the implementation of the enterprise strategy. The marketing strategy reflects the methods by which the sale of goods and services will be carried out, and the financial strategy determines the most effective options for using the financial resources of the enterprise.

As noted in the previous sections, the foundation of operations management is the management of operating systems. Such systems use the enterprise's operating resources to transform a factor of production (the "input") into a product or service of its choice (the "output"). The "input" may be a raw material, a customer, or a finished product received from another operating system. As seen in fig. 4.1 Operational resources include five main elements, which are called 5Ps operating management (SPs of operational management) from the following English words: personnel (People), plants (Plants), materials and components (Parts), processes (Processes) and planning and control systems (Planning and Control Systems). Personnel is a labor force directly or indirectly engaged in the production of products or services. Factories - these are factories, production and service divisions of the company, where products are manufactured or services are provided. Materials and accessories are undergoing changes in the production system. Processes cover the equipment and stages of production of products and services. Planning and management systems are the procedures and information used by managers during the operation of an operating system.

Rice. 4.1. in

In the process of production, raw materials change (transform) their state and turn into a product that a person needs. The operational process is carried out by one or a group of employees and consists of a set of technologically interconnected operations united by the unity of the final product. The process includes work operations that make up organizationally indivisible repeating homogeneous elements of this process. The external sign of the operation is the invariability of the composition of the performers, objects and tools of labor. Each operation is divided into smaller elements, called working methods, which, in turn, consist of working movements.

The production transformation may have the following character.

Physical transformation as a result of the manufacturing process.

Change of location as a result of transportation.

Exchange as a result of retail trade.

Warehousing as a result of warehousing.

Physiological transformation as a result of medical care.

Information transformation as a telecommunications service.

Of course, the transformations listed above are not mutually exclusive. For example, a supermarket simultaneously allows the customer to 1) compare the prices and quality of the goods offered (information transformation), 2) store certain goods in a warehouse until they are needed (warehousing), and 3) sell goods (exchange).

Thus, we can make the following definition: resources are controllable factors of production, possess valuable properties and transformative capabilities needed to ensure the operation and development of production processes in order to achieve planned results.

Regarding the measurement of resources, the following concepts are used:

"Bottleneck" or "insufficient resource" - any resource whose capacity (throughput) is less than the need for it. This is a limitation within the system that limits the funds in the system. An insufficient resource may be a machine, parts of unskilled personnel or non-specialized tools.

"Excess resource" - any resource whose capacity exceeds the need for it, that is, such a resource cannot work continuously, since in this case a larger volume of products (services will be provided) will be manufactured than necessary.

"Limited Power Resource" - a resource, the loading of which practically corresponds to its capacity. It can become an insufficient resource if its work is not clearly planned.

consultation manage not only the resources and processes discussed above. It is possible to mature the goals only when the products are sold or through the provision of services. And this is connected with the external environment, which is the consumer of the product being produced, and the source of supply of resources. After all external environment is not only a source of threats, but also opportunities. In other words, management is not limited to resource management, production, but the enterprise as a whole. This concept is associated with making a profit, that is, achieving the goal of the enterprise. Since we are considering operating system As an object of situational management, we, first of all, should be interested in answering the question of what opportunities we currently have and what opportunities we should have in the future to ensure the competitiveness of the enterprise.

Considering the operational activities, it is necessary to note the differences between the processes of production of products and the provision of services in enterprises and organizations. The main difference is that the process of providing services is characterized by a non-existent property, while the product is the physical result of a particular production operation. Figuratively speaking, a service is that "falling on the leg does not cause pain." Other differences are that in the process of providing services, the good location of the service premises is often a very important factor, as well as the fact that we often offer participants in it ourselves, which practically does not happen in the production process. However, this statement should not be taken unequivocally either. For example, manufacturers often provide services in the form of after-sales service for their products; many service businesses often carry physical products that they offer to their customers, or consume materials themselves in the process of providing services. Suffice it to recall McDonald's. It manufactures products, but since these products are offered in such a way that they provide some contact with consumers and thereby complete the service process, this company belongs to the service sector.

Further, if we consider the issue from the point of view of operations, it should be noted that in the process of consuming most services, in contrast to the consumption of tangible products, customers are directly at the place of their provision: in the hall of a restaurant, in a surgical operating room, in a train compartment, etc. d. (depending on the industry). In addition, there are also many areas in which the material "entrances" and "exits" are involved implicitly, hidden. For example, major airlines, banks, and insurance companies typically maintain large back offices to provide customer contact. In the course of the work of such offices, documents and information are processed (tickets, checks, complaints, etc.), and, consequently, the process of managing them largely coincides with the process of managing a factory.