April 2004
ISSN 0717-1560
MANAGEMENT problems IN THE PUBLIC HEALTH SYSTEM AND
ESTIMATE OF LOSSES DUE TO negligence
Rodrigo Castro[1]
Social SERIES
REPORT
no. 81
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management PROBLEMS in the public health system and estimate of losses due to negligence
Executive Summary
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After 10 months of discussion in the Senate’s Health Commission, the law reforming healthcare authority was approved. The law introduces significant modifications to the healthcare system with regard to healthcare quality and management, permitting to improve conditions of access to and timeliness of care for public healthcare users. The law provides for the creation of a National Health Commission, and entity that will be in charge of overseeing the FONASA (National Health Fund) and the ISAPRES (private health institutions) which are subject to the same rules. It will also be responsible for certifying hospitals and clinics, as well as physicians. Also, it will see that the guarantees offered by the AUGE (AUGE stands for “Universal Healthcare with Explicit Guarantees”) are fulfilled. In addition, 56 hospitals will be classified as self-managed in a network. This will provide greater flexibility in the use of resources and personnel, ending with current rigidities. Moreover, the Ministry of Health will set quality standards that must be followed by hospitals and clinics in order to be certified. Two undersecretary offices will be created, one to oversee the operation of hospitals and another for the application of public health policies.
This study gathers background information published in the written press related to cases of administrative or medical negligence and lack of priority in public health establishments for the 1998-2003 period. It is estimated that the Government has lost CH$122.7 billion during the abovementioned period, in other words, three times the hospital debt for 2003, which totals CH$35 billion.
This figure is much higher than the deficit of primary healthcare, with totals CH$78 billion and the investment necessary to rebuild and refurbish the Salvador hospital, which totals approximately CH$37.8 billion.
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I. EstimaTE OF LOSSES
T
his study compiles information about cases of administrative and medical negligence and lack of priority in public health establishments between 1998 and 2003. It is estimated that the Government has lost CH$122.7 billion for this cause during the abovementioned period. This is equivalent to the three times the hospital debt (Chart No. 2) until 2003, which totals CH$35 billion[2]. This figure is also much higher than the primary healthcare deficit of CH$78 billion and than the investment needed to rebuilt and refurbish the Salvador hospital, which totals approximately CH$37.8 billion.
TABLE No. 1 Losses (in $CH million) associated with cases of Administrative and Medical Negligence, Poor Management and Lack of Probity
2003 / 2002 / 2001 / 2000 / 1999 / 1998MN* / 1,288 / 13,000 / 137 / 260 / 200 / 300
AN* / 70 / - / 11.000 / 72 / 40 / 100
PM* / 500 / 114 / - / 45,900 / 15,770 / 1,500
LP* / 32,450 / 28 / 20 / - / - / -
Total / 34,308 / 13,142 / 11,157 / 46,232 / 16,010 / 1,900
Source: El Mercurio, La Tercera, Las Ultimas Noticias.
MN: Medical Negligence
AN: Administrative Negligence
PM: Poor Management
LP: Lack of Probity
Only in 2003 losses totaled CH$34.3 billion, CH$32.4 billion of which correspond to lack of probity, CH$500 million to poor management, CH$70 million to management negligence and CH$1.3 billion to medical negligence[3].
We can also see that in 2002 public establishments recorded 26 cases of medical negligence, 7 cases of administrative negligence, 10 cases of poor management and 9 cases of lack of probity. In total the cases of negligence generate losses of CH$1.06 billion. Twenty billion of which corresponded to lack of probity; CH$114 million to poor administration; there is no information on the written press about administrative negligence; and CH$925 million correspond to medical negligence. It is worth noting that according to the press complaints due to medical negligence total CH$13 billion in 2002, 46.9% of which are concentrated in Region V.
CHART No. 1 Number of Cases of Administrative and Medical Negligence, Poor Management and Lack of Probity
Source: El Mercurio, La Tercera, Las Ultimas Noticias
On the other hand, 12 cases of medical negligence, 4 cases of administrative negligence and 1 case of lack of probity were recorded by the Chilean written press in public establishments in 2001. Total cases of negligence generated CH$11.2 billion in losses for the Government; CH$137 million of which corresponded to medical negligence and CH$20 million to lack of probity.
In 2000, 6 cases of medical negligence, 5 cases of administrative negligence, 4 cases of poor administration, and 1 case of lack of probity were recorded in public establishments. Cases of negligence totaled approximately CH$46.2 billion in losses for the Government, CH$72 million of which corresponded to administrative negligence, CH$45.9 million to poor management (CH$45 billion of which are medicine debts) and CH$260 million to medical negligence.
CHART No. 2 Hospital Debt (in million CH$ 2002)
Source: Statistics, Ministry of Health.
In 1999, 3 cases of medical negligence, 3 cases of poor management and 1 case of lack or probity were recorded by the Chilean written press in public healthcare establishments. In total the cases of negligence generated the government losses of approximately CH$16 billion. CH$40 million of these losses correspond to administrative negligence, CH$15.7 billion to poor management (CH$15 billion of which correspond to debts of materials) and CH$200 million to cases of medical negligence.
During 1998, 9 cases of medical negligence, 3 cases of administrative negligence and 4 cases of poor management were recorded in public healthcare establishments by the Chilean written press. In total, cases of negligence generated the government losses of approximately CH$1.9 billion, CH$100 million of which corresponded to administrative negligence, CH$1.5 billion to poor management, and CH$300 million to medical negligence.
II. New Legislation and proposals
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ithin this context, it is worth noting that after 10 months of discussion in the Senate’s Health Commission, the law reforming the healthcare authority was approved. The law introduces significant modifications to the healthcare system with respect to healthcare quality and management, permitting to improve conditions of access and timeliness to public healthcare users. The law provides for the creation of a National Health Commission in charge of overseeing the FONASA (National Health Fund) and the ISAPRES (private health institutions), which are subject to the same rules. It will also be responsible for certifying hospitals and clinics, as well as physicians. In addition it will see that the guarantees offered by the AUGE (“Universal Attention with Explicit Guarantees”) are complied with.
Moreover, 56 hospitals will be classified as self-managed in a network. This will provide greater flexibility in the use of resources and personnel, ending with current rigidities. In addition, the Ministry of Health will set quality standards that must be followed by hospitals and clinics in order to be certified. Two undersecretary offices will be created, one to oversee the operation of hospitals and another for the application of public health policies.
Although undoubtedly these will be important modifications, there is still a long way to go to achieve full public healthcare modernization, in the light of the various management problems—cases of administrative and medical negligence, lack of probity and poor management—which the sector has presented over the past six years.
We must ask ourselves, which are the medium and long-term tasks that must be addressed to solve the different management problems of the public health sector? Progress has to be made in two fronts.
First, public hospitals must be autonomous institutions administered with flexible rules like those that govern corporations. The must be financed with resources obtained from serving public and private sector beneficiaries, competing among themselves and with private establishments to attract clients.
In fact, the funding system of hospitals managed by the public health services must be changed, so that resources destined to finance health services are fully transferred in accordance with the number of services provided. Also, the responsibilities and attributions of the directors of healthcare establishments must be similar to those of the directors of private institutions. After a period of transition, hospitals should have an independent juridical structure, the Government holding a minority share, giving a preemptive option to establishment workers, and open to private entities interested in associating. These healthcare corporations should compete among themselves and with other private organizations to provide healthcare to the population covered by the public and private health systems, and they must be fully autonomous.
Municipalities must compete among themselves and with the private sector in primary care in order to attract beneficiaries of the institutional system as well as clients from the free-election FONASA, ISAPRE systems and private individuals requiring healthcare services.
Municipalities could subsequently become involved in the administration of social security funds, collecting obligatory healthcare contributions and obtaining the government subsidy aimed at financing all or part of healthcare per capita spending. The municipalities could participate in the development of government healthcare and overall healthcare programs, competing with the private sector. They could also manage resources by subcontracting third parties to provide services or carry out both functions.
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IIi. aPPENDIX
Class / Case / Hospital / Sum / Effect / Source / DateMN / A woman was diagnosed cancer and she was removed one of her breasts. She was also removed, without her consent, part of her womb, thereby preventing her from ever bearing a baby again. The pathology report establishes that she never had cancer, and the removal of part of the womb was a mistaken procedure. / Iquique Hospital / Physical and psychological damage to a woman. / EM / 7/02/03
MN / A mother denounced that her child died in her womb because of MN as the physician in the hospital got confused with the baby’s gestational age. / San José Hospital / Death of a fetus with 40 weeks of gestational age. / LC / 5/02/03
MN / The disappearance of the body of a dead infant was denounced after the infant was delivered in the San Bernardo Parish Hospital. The mother was never allowed to see the baby and it is believed that this may have been caused by the intention of concealing a potential case of MN. / San Bernardo Parrish Hospital / Death and disappearance of an infant. / LC / 5/02/03
MN / No one was considered guilty of the death of 12 babies in the Gustavo Fricke Hospital after an investigation of 7 months. / Gustavo Fricke Hospital / Death of 12 babies / EM / 10/02/03
MN / Family will demand the hospital for potential MN due to the death of a child caused by a brain aneurism: he was seen a couple of minutes and only given an injection of Dipirone and Torecan. / El Pino Hospital in San Bernardo / 11/02/03
MN / Mother denounces that a midwife left dressings inside her body after delivery causing her a serious infection. / Cordillera Oriente Hospital / LC / 19/02/03
MN / Woman files a complaint because of the death of her husband, who was diagnosed a headache, when he actually had a brain aneurism. He was finally operated but died a few hours after surgery. / Institute of Neurosurgery / Death of patient. / LC / 5/01/03
MN / Physician accused of causing the death of an infant due to a poor delivery procedure. / Luis Tisné Brousse Hospital / LC / 13/01/03
MN / Two-month-old baby supposedly died due to MN resulting from a surgical procedure that got complicated with an infection, which caused the baby’s death. / Sótero del Río Hospital / Death of baby. / LC / 6/07/03
MN / A woman that was run over in June was released from hospital and now her leg must be amputated. / Sótero del Río Hospital / Leg amputation / LT / 13/07/03
MN / A family filed a protection recourse against the hospitals because it considers that they are responsible for the paralysis and poor health condition of an elderly man caused by a drug that was given to him. / Regional Concepción Hospital and Higueras Hospital / Paralysis of elderly man. / LT / 2/03/03
MN / A woman with a 5-month pregnancy died of a myocardial infarction waiting to be seen by the doctor. She was an employee of the same hospital. Her husband filed a complaint for MN. / San José Hospital / Death of pregnant woman / LC / 15//03/03
MN / The Metropolitan Health Service must pay CH$5 million to patient who was diagnosed HIV (Aids) instead of HCV (type C hepatitis). / San Borja Arriarán Hospital / CH$5 million indemnity / RE / 31/03/03
MN / Baby suffering pneumonia died supposedly due to late medical care. / Regional Antofagasta Hospital / Death of baby / EM / 24/04/03
MN / Three patients were left needles inside their bodies after surgery. They filed complaints for MN against the doctors and the hospitals. / Regional Antofagasta Hospital / Discomfort and disability to work normally. / EM / 16/04/03
MN / A Psychiatrist of the Temuco Regional Hospital verbally ill treated a 21 year-old patient. / Regional Temuco Hospital / LC / 31/05/03
MN / Clergyman was operated of Parkinson’s disease and was left neurologically disabled, in a fetal position. This was supposedly caused by the breaking of a brain artery during surgery. / Universidad de Chile Hospital / Patient’s neurological disability / LS / 22/05/03
MN / A six-year-old child admitted to hospital with a diagnosis of pneumonia fell when he was being examined, severely knocking his head. The child is seriously ill. The hospital recognized the error and will conduct an internal preliminary investigation. / San Juan de Dios Hospital / Fall caused repeated epileptic attacks. / LT / 22/05/03
MN / Four physicians are processed due to the death of a patient in the Punta Arenas Hospital apparently due to medical negligence because of inopportune care. / Punta Arenas Hospital / Death of patient. / LUN / 17/05/03
MN / 594 cases of medical negligence were recorded during the 2000-2001 period, 551 of which occurred in hospitals. / EM / 7/05/03
MN / The father of triplets who died in the Talca Hospital filed a millionaire demand against the Government due to alleged medical negligence. It is estimated that the demand will total 1 billion CH$. / Talca Hospital / CH$1 billion / Death of three infants / LUN / 4/06/03
MN / 30% of medical negligence demands are related to problems resulting from anesthesia. / LT / 16/06/03
MN / Excessive delay in delivery because the person did not have a check to give in guarantee, resulted in serious problems to the infant, who is kept in the Intensive Care Unit. / Teachers’ Hospital / LC / 27/08/03
MN / Audit in Sótero del Río Hospital after the death of a 4-month-old baby was denounced apparently due to medical negligence. / Sótero del Río Hospital / LUN / 10/08/03
MN / A woman files a complaint against the hospital due to medical negligence after one of her legs was amputated after being run over some weeks before. She had been dismissed from hospital before the amputation. / Sótero del Río Hospital / LT / 13/08/03
MN / A woman was diagnosed a stomach ache and she actually had leukemia, dieing of that diagnosis. The family filed a complaint due to alleged medical negligence. / Salvador Hospital / LC / 13/09/03
MN / Five new born babies caught a nosocomial infection and are in serious condition. An investigation was started to determine the personnel’s responsibility. / Regional Antofagasta Hospital / EM / 8/09/03
Fire in Hospital Sótero del Río obliged the evacuation of 150 patients. / Sótero del Río Hospital / EM / 8/09/03
MN AN / Non-skilled personnel is giving anesthesia in public hospitals, in some cases even cleaning personnel and other non-qualified personnel are involved. / MINSAL / EM / 6/09/03
MN / A woman that was diagnosed cancer was given morphine during 2 years, believing she had a terminal tumor. / Hospital Carlos Van Buren, Valparaíso / LT / 4/09/03
MN / Cases of medical negligence grew 100% in the public sector in the 2000-2001 period. The figure rose to 619, 184 of which resulted in the patients’ death, 21 in disability, and the rest in other problems. / LH / 10/09/03
MN / A pregnant woman underwent a cesarean section when the baby was already dead. Under the effects of the anesthesia she was asked to sign the authorization for the operation, releasing the hospital of any medical error. / Regional Rancagua Hospital / LC / 9/10/03
MN / A dentist was accused of quasi delict of serious injuries caused when breaking a young person’s jaw. / CH$3 million / Jaw fracture. / EM / 7/10/03
MN / Parents of an 8-year-old child, whose sex was changed, announce they will sue the hospital. / Sótero del Río Hospital / EM / 20/11/03
MN / The breakdown of the ambulance put at risk the life of a woman with a fulminating hepatitis type A. The ambulance that was transporting a kidney that would be transplanted on her had a flat tire. / Universidad de Chile Hospital / EM / 4/11/03
MN / Justice ordered payment of 115 million to a teacher who was amputated an arm because of medical negligence. / Regional Concepción Hospital / $115 million / LC / 5/11/03
MN / Physician was processed due to double negligence because he left a dressing in the neck of a patient who was removed a cyst. Prior to that he had faced another legal action due to medical negligence, which obliged the Concepción Health Service to pay US$65 million. / Regional Concepción Clinical Hospital. / $65 million / Pronounced scar on cervical area. / EM / 2/12/03
MN / A complaint was filed against the Luis Calvo Mackenna Hospital because a young person was admitted to the Intensive Care Unit although the center new there was an infection in the hospital. / Calvo Mackenna Hospital / LUN / 19/12/03
MN / The Talcahuano health service must pay indemnity to the parents of a child that was born with irreversible neurological damage because of heart arrest due to delivery induction. / Higueras Hospital / $100 million / Neurological damage / EM / 20/12/03
MN / Hospital delivered the wrong corpse. The Hospital’s Director assumed the responsibility. / Claudio Vicuña San Antonio Hospital / EM / 9/04/03
MN / 867 thousand false indigents are given healthcare at public hospitals generating an extra expense of 70 billion for the government. / 70 billion / LS / 26/05/03
MN / The Exequiel González Cortés hospital decided to suspend all types of surgeries due to the serious medical instrument deficiencies and lack of inputs. / Exequiel González Cortés Hospital / Suspension de 50 surgical operations. / LUN / 5/06/03
AN / Waiting times for chronic kidney failure patients tripled as a result of the AUGE. / LH / 16/08/03
AN MN / Deficient healthcare in Region V. More than 10 thousand people are in a waiting list to undergo surgery in Carlos Van Buren and Gustavo Frick Hospitals. / Carlos Van Buren and Gustavo Fricke Hospital / LS / 16/09/03
AN / People die on the floors of the corridors of the Carlos Van Buren Hospital in Valparaíso mainly due to lack of beds. / H Carlos Van Buren Valparaíso / Death of patients due to lack of resources / EM / 4/09/03
AM / A collapsed Gustavo Fricke Hospital cannot meet demand. This is accompanied by a strong debt. Suppliers stopped providing materials. / Gustavo Fricke Hospital / EM / 27/11/03
PM / Salaries of hospitals grew 280% between 1999 and 2002, whereas productivity only grew 10%. / EM / 16/11/03