Republic of Serbia

MINISTRY OF HEALTH

Day Surgery/ Day Hospital:

Challenging existing models of service delivery
in a transitional country

Jeki I.M,
Katrava A, Boulton G, Milojkovi A, Andrejevi V, Koumpis N,
uki V*, Peko P*, Dmitrovi T*, Drakovi D**, Dujmovi F**, Trenki S***,Pavlovi R****
*
**
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EAR/EU SOFRECO Technical Assistance-TA Team, Belgrade

Clinical Centre of Serbia, Belgrade
Clinical Centre of Vojvodina, Novi Sad
Clincal Centre of Ni
Clinical Centre of Kragujevac

TA for Capacity Building for Tertiary Care Services

An EU-funded project managed by the European Agency for Reconstruction

Context
Day Surgery/Day Hospital models of service delivery are
in their early stage in Serbia.
The health reform targets call for 3-5% annual increase
in ambulatory services.
The EU/EAR Project provided to the Ministry of HealthMoH has been charged with
reforming tertiary care services and
implementing an EIB loan of EUR 200M in the beneficiary
institutions: the Clinical Centres in Belgrade, Novi Sad, Nis and
Kragujevac for their rehabilitation and strategic development.

Four largest university hospitals in Serbia together have

over 220,000 inpatients
120,000 surgeries annually
rather low day surgery/day hospital cases rates.
TA for Capacity Building for Tertiary Care Services
An EU-funded project managed by the European Agency for Reconstruction

Background
International surveys Country benchmarks for day
surgery activity
International Association for Ambulatory Surgery &
OECD
Results of World Wide Day Surgery Activity 2003
18 countries or regions, 37 procedures
In most countries day surgery activities are within public
hospitals (In USA where activity is very high, the percentage of private free standing
units is also very high)

Reimbursement systems are very different

USA, Canada and Scandinavian countries have high
percentage of day surgery procedures
Countries having high rate of day surgery in some specialties
may have significantly low rate in other specialties
TA for Capacity Building for Tertiary Care Services
An EU-funded project managed by the European Agency for Reconstruction

Background
International variations in availability and diffusion of day surgery

Micro level
Patients or physicians may not want, or may not be able to
use day surgery
Hospital characteristics, such as the number of hospital beds

Macro level
Health care system characteristics, such as financing and
insurance influence the shift to day surgery

TA for Capacity Building for Tertiary Care Services

An EU-funded project managed by the European Agency for Reconstruction

Background
Key factors to Consider as Care Shifts to Day Surgery + Outpatient

Cost

Payer mix

Ancillary
Demand

Increased supply,
technology costs

Health
Insurance
coverage

Related billable
volume

Length-of-stay
cost savings

Impact of
Competition

Market Growth
Potential

Private
physician offices

Improve Outcomes
Reduced risk and
pain

TA for Capacity Building for Tertiary Care Services

An EU-funded project managed by the European Agency for Reconstruction

Background
Slow Pace of Clinical Proliferation
Technology-Driven Outpatient Growth

100%

Percentage
Outpatient

0%
Time
TA for Capacity Building for Tertiary Care Services
An EU-funded project managed by the European Agency for Reconstruction

Background
Trend in take up of day surgery

TA for Capacity Building for Tertiary Care Services

An EU-funded project managed by the European Agency for Reconstruction

Background

Even when the evidence for change to clinical practice is so strong

and seemingly self evident, there is no guarantee that it will be
adopted.

This is a classic management of change issue that involves

soft factors such as professional attitudes
hard factors such as data / resources / appropriate funding
system from the Health Insurance Fund - HIF as an incentive for this
change.

Currently, HIF funds the hospital based on a hospital day and

therefore operating budget disincentives to shift to day surgery
because the HIF will not reimburse the hospital for a day case.

This causes certain deviation/adjustments in recording/invoicing of

the day surgery cases towards the HIF, resulting in lower rate of
recorded day surgery cases that have really been performed
TA for Capacity Building for Tertiary Care Services
An EU-funded project managed by the European Agency for Reconstruction

Methods
Over past seven years, the Clinical Centres have still been
operating under
unchanged legislation
unchanged model of service delivery
fixed operating budgets

These represents limitation for the hospitals to respond to

increasing demands of emerging ambulatory service
delivery model.
The EU/EAR Project is a vehicle with capital investments
providing an opportunity
to restructure space for more day surgery and day hospital
to facilitate professionals buy-in to this model of service delivery
to motivate MoH to support this change due to systemic
improvement in quality of care and lowering costs
to influence MoH and HIF to change financing models.
TA for Capacity Building for Tertiary Care Services
An EU-funded project managed by the European Agency for Reconstruction

Methods -

Organization of day surgery

Accommodation for day surgery

Most cost-effective option is a self-contained day surgery unit, with its own
admission suite, theatre and recovery area together with administrative
facilities.
Less satisfactory arrangement is a day case ward with patients going to
the main operating room

Management of the day surgery unit

Day surgery needs a rigorous management structure including
lead clinician
day surgery manger/senior nurse
other staff

Changes of working practices

Specific training for the surgeon and anesthetist in day surgery techniques
Local incentives, such as the availability of enhanced resources to those who
shift treatment to day surgery
Dedication of theatres for day case are preferred for better output, compared to
theatre/ward mix with inpatient surgery

The advantages to patients

Opportunities to see and experience day surgery
TA for Capacity Building for Tertiary Care Services
An EU-funded project managed by the European Agency for Reconstruction

Methods
Research within the Clinical Centers
Research was conducted as
qualitative questionnaire of staff
quantitative/qualitative measurement of operating facility utilization

Research covered
112 operating theatres
over two weeks period
analyzing over 3000 surgical interventions

Qualitative questionnaire (anonymous) was distributed

among top and medium management in all 4 Clinical Centers
covering 320 managers of different level
TA for Capacity Building for Tertiary Care Services
An EU-funded project managed by the European Agency for Reconstruction

Results

It is an internationally accepted standard that 70% of elective surgery

cases can be undertaken in day setting.
In 2008, specific annual targets for 25 selected procedures that can
be done safely and effectively as day cases will be set in a step-wise
fashion.

Results of the survey

There is no formalized day surgery in Serbia for most of procedures
There is uneven and non systemic development of day surgery in CCs
There is a different understanding of day surgery definition and
procedures between medical employees
Still, there is awareness of day surgery importance and willingness to
change towards day surgery
Survey data shows deviation between recorded and actual day
services provided
There are no financial incentives for providers to shift to day surgery in
spite all other benefits
Expected list of procedures for day surgery is very similar with UK
basket of 25 procedures
TA for Capacity Building for Tertiary Care Services
An EU-funded project managed by the European Agency for Reconstruction

Results

There is a potential to carry out more day surgery and elective operations
within current resources by
redistributing and dedicating theatres
improving scheduling
reducing cancellations
decreasing gaps between patients

improving the management of existing theatre resources.

However

There is no functional scheduling and reporting system for utilization

There is no theatre/ward booking system prior to admission of patients;
There is no measurement of utilization of operating facilities;
Members of OR teams are not fully trained for day surgery work flow

Still
There is evidenced increase in day surgery in Serbia from 2002.
Thorough Action plan must be implemented in order to reach targets in day surgery
TA for Capacity Building for Tertiary Care Services
An EU-funded project managed by the European Agency for Reconstruction

Results
Observation by hospital staff for
improvements needed in development
of day surgery

Space
Equipment
Change of financing pattern
Training and education of manpower
Improvement of recording/measurement procedures
TA for Capacity Building for Tertiary Care Services
An EU-funded project managed by the European Agency for Reconstruction

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

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

Conclusions
Defining procedure-specific annual percentage rates on
the five year period (2008-2012) basis
Developing an implementation plan with different targets
for each of the 25 potential day cases have been done
(eg. 30% of cataract extractions and 20-30% of hernia
repairs as day cases in the first year),
Mentioned should secure sustainable shift towards
ambulatory care model.

TA for Capacity Building for Tertiary Care Services

An EU-funded project managed by the European Agency for Reconstruction