organizational aspects dr. juan batlle hospital dr. elias santana santo domingo, rep. dominicana

ORGANIZATIONALORGANIZATIONALASPECTSASPECTS

DR. JUAN BATLLEDR. JUAN BATLLE

HOSPITAL DR. ELIAS SANTANA

Santo Domingo, Rep. Dominicana

CLEAR GOALS

IF YOU DO NOT HAVE A PLAN, YOU CAN PLAN TO FAIL.

ITEMS TO BE DISCUSSED

A. IDENTIFICATION OF NEED

B. QUANTIFICATION OF RESOURCES

C. SELECTION OF ADMINISTRATIVE CULTURE

D. IMPLEMENTATION OF RESOURCES

E. SELF-EVALUATION

F. VISION OF FUTURE

IDENTIFYING NEED

NATIONAL INVESTIGATIONS POPULATION CENSUS PUBLISHED STUDIES OF

BLINDNESS PREVALENCE OF BLINDNESS

BETWEEN 0.4% & 0.6% HALF OF THE BLIND CASES

SUFFER WITH CATARACTS

HOW MANY BLIND PEOPLE EXIST IN LATIN AMERICA?

THERE ARE FEW INVESTIGATIONS AND NO CENSUS 1987 IN THE CENSUS OF OMS: 1,760,000 MINIMUM

2,760,000 MAXIMUM

TOTAL POPULATION: 397,000,000 HALF OF THEM SUFFER FROM CATARACTS IN A POP. OF 400 MILLION INHABITANTS IN LATIN

AMERICA, SOME 2 MILLION ARE BLIND IN BOTH EYES

APPROXIMATELY 1 MILLION ARE BLIND BECAUSE OF CATARACTS

PREVENTION OF BLINDNESSCENTRAL AMERICACOUNTRY POPULATION PREVALENCE

MEXICO 79,000,000 500,000-1,00,000

GUATEMALA 8,000,000 30,000-50,000

HAITI 6,000,000 30,000-50,000

DOMINICAN REPUBLIC

8,000,000 30,000-50,000 (33,000)

JAMAICA 2,500,000 5,000-10,000

PANAMA 2,000,000 5,000-10,000

EL SALVADOR 5,000,000 15,000-25,000

CUBA 10,000,000 30,000-50,000

COSTA RICA 3,000,000 10,000-15,000

HONDURAS 5,000,000 20,000-35,000

NICARAGUA 4,000,000 15,000-25,000

PREVENTION OF BLINDNESS IN S. AMERICA

COUNTRY POPULATION PREVALENCE

BRASIL 135,000,000 500,000-1,000,000

COLOMBIA 28,000,000 100,000-150,000

PERU 20,000,000 80,000- 20,000

ECUADOR 9,000,000 35,000- 50,000

CHILE 12,000,000 40,000- 60,000

VENEZUELA 15,000,000 50,000-70,000

PARAGUAY 3,500,000 10,000-15,000

URUGUAY 31,000,000 110,000-165,000

ARGENTINA 29,000,000 100,000-150,000

BOLIVIA 8,000,000 25,000-40,000

INFANT BLINDNESSIN LATIN AMERICA

COUNTRY PERU BOLIVIA URUGUAY CHILE JAMAICA

EXAM. 405 78 155 3 esc. 100

DATE 1986 1988 1988 1986 1986

CORNEA 6 23 4 8 5

GLAUCOMA 9 10 12 16 12

RETINA 24 23 24 31 15

O.N. ATROPHY 9 10 9 7 15

OTHERS 35 13 23 34 8

Source: CBM

OPHTHALMOLOGIST/ POPULATIONCOUNTRY OPHTH. / POPULATION

HAITI 1:230,000

NICARAGUA 1:200,000

ECUADOR 1:129,000

GUATEMALA 1:111,000

COSTA RICA 1:85,000

BOLIVIA 1:76,000

BRASIL 1:67,000

R. DOMINICANA 1:56,000

COLOMBIA 1:40,000

PERU 1:27,000

BLINDNESS SURVEY IN DOM. REPUBLIC (1995)

PREVALENCE = 0.45% BLINDS PRINCIPAL CAUSE = 46% CATARACT SECOND CAUSE = 22. 5% GLAUCOMA OUT OF A POPULATION OF 7.5

MILLION, 16,570 ARE BLIND DUE TO BILATERAL CATARACTS

MOST OF THEM DO NOT GET OPERATED BECAUSE OF ECONOMIC LIMITATIONS.

CAUSES OF BLINDNESSIN LATIN AMERICA

CATARACT GLAUCOMA DIABETIC RETINOPATHY CORNEAL LEUKOMA

SOCIOECONOMIC STRUCTURE OF L.A

HIGH CLASS 5-10% MIDDLE CLASS 10-40% GHETTOS 10-40% RURAL POPULATION 20-80%

MAIN PROBLEM

NOBODY WANTS TO OPERATE ON THE POOR AND INDIGENT PEOPLE.

¿WHO PAYS?

THE PATIENT 35% RELATIVES 10% PRIVATE INSURANCE 5%

SOCIAL SECURITY 20% FEDERAL GOVERNMENT 30%

IN DOMINICAN REPUBLIC

OBSTACLES FORCATARACT SURGERY

MONEY FEAR DISTANCE CONFORMITY IGNORANCE BELIEFS

CATARACT SURGERY SHOULD BE :

AT A REASONABLE PRICE CONVENIENTLY ACCESSIBLE WITH APPROPRIATE

TECHNOLOGY

AVERAGE COST OF CATARACT SURGERY

AFRICA US$ 8-10 INDIA 12-10 HAITI 30-50 DOMINICAN .REP 100-300 COLOMBIA 300-500 CANADA 700-900

SIGHTFIRST MEGAPROJECTS

PROJECTS OF 200+ CATARACT OPERATIONS TOTALLY FINANCED

IDENTIFY CATARACTS AS THE ENEMY

IT IS A MODEL TO BE FOLLOWED AND IMITATED BY THE FEDERAL GOVERNMENT.

ROTARY`S MEGAPROJECTS

1,000 OR MORE OPERATIONS

DIRECTLY FINANCED

MANAGEMENT IMPORTANT AND ALSO SELF-EVALUATION

SEEING 2000 PROGRAMOF IEF

DIRECTED AT BLINDNESS PREVENTION IN INFANTS

SUPPORTS PROGRAMS FOR HYPOVITAMINOSIS, CATARACTS AND CONGENITAL GLAUCOMA

FINANCIALLY DEPENDENT ON AID MANAGEMENT IS VERY IMPORTANT

COLLABORATION WITHCHRISTOFFEL

BLINDENMISSION

YOU ARE IDENTIFIED BY THEM THEY HELP YOUR PROGRAM USUALLY

FOR 5% OF THE TOTAL COST VERY RESPECTFUL OF INSTITUTIONAL

GOALS AND RESOURCES THEY LOOK FOR LONG-TERM STATE

SUPPORT VERY PROFESSIONAL , STRICT, AND COST

CONSCIOUS

OPS PROGRAMS

GLOBAL SENSE OF PREVENTION IN A NATIONAL HEALTH PLAN.

THEY WORK DIRECTLY WITH THE HEALTH MINISTER

HEALTH MAINTENANCE ORGANIZATIONS ARE CREATED TO COMPETE AMONG THEMSELVES AS SUPPLIERS

MANAGEMENT STRATEGIES ARE SOUGHT TO IMPROVE PROGRAMS

IT CAN BE VERY POLITICAL ALTHOUGH THE ONG’S ARE SUPPORTED GENEROUSLY

CULTURE OF ORGANIZATIONS PYRAMIDAL VERTICAL SATELLITES MISSIONARY PRIVATE PRACTICE PUBLIC SERVICE COMBINATION OF PRIVATE

AND PUBLIC

PYRAMIDAL CULTURE

B O A R D O F D IR E C TO R S

S E C R E TA R Y

R E S ID E N T 1 R E S ID E N T 2

D IR E C TO R A C A D E M IC O IN V E S TIG A C IO N

C H IE F O F S TA F F

IN S TR U M E N TIS T C IR C U L A TIN G N .

C H IE F O F O .R .

H E A D N U R S E

M E D IC A L D IR E C TO R

A C C O U N TA N T

D A TA TE R M IN A L O P D A TA TE R M IN A L O P

P R O G R A M M E R

A U D ITO R

C O M P TR O L L E R

O U TP A TIE N T C L IN IC

S O C IA L W O R K E R P R E O P E V A L U A TIO N

P R O G R A M A C IO N

S U R G E R Y

E X E C U TIV E D IR E C TO R

P R E S ID E N T TE S O R E R O

PYRAMIDAL CULTURE THERE IS FUNCTIONAL HIERARCHY AND

JURISDICTION FOR EACH JOB DESCRIPTION

EACH EMPLOYEE IS RESPONSIBLE TO HIS SUBORDINATES AND BOSSES

THERE ARE MANY BOSSES, EACH WITH A NUMBER OF SUBORDINATES, BUT THE ONES THAT WORK THE MOST ARE AT THE BOTTOM OF THE PYRAMID

NOBODY IS INDISPENSABLE IN THIS SYSTEM

SATELLITE CULTURE

PRESIDENT

ISLAND OR SATELLITE CULTURE

EACH ISLAND HAS ITS OWN AUTONOMY BUT ALL THE ISLANDS ARE RESPONSIBLE TO ONE CHIEF

THE CHIEF HAS TO MOVE AROUND THE DIFFERENT ISLANDS TO SUPERVISE THE WORK DONE

REQUIRES MUCH COMMUNICATION, LOYALTY, AND CONFIDENCE

THERE IS LITTLE INTERACTION BETWEEN ISLANDS ESPECIALLY IF VERY REMOTE

VERTICAL CULTURE

B O A R D O F D IR E C TO R E S

TR E A S U R E R

C O R O N E L

TE N IE N TE

C A B O

R E C L U TA

R A S O

S A R G E N TO

M A Y O R

G E N E R A L

G E N E R A L S U P E R V IS O R S E C R E TA R

P R E S ID E N T

VERTICAL CULTURE IS TYPICAL OF MILITARY OPERATIONS BUT

ALSO IN RESIDENCY TRAINING PROGRAMS INFORMATION IS USUALLY QUITE ALTERED

BEFORE IT MAKES IT TO THE CHIEF THE CHAIN OF COMMAND IS EASILY

BROKEN IF SOMEONE IS MISSING EVERYONE IS AWARE OF WHAT THE CHIEF

WANTS OR THINKS THE CHIEF HAS TO WORK QUITE HARD BUT

DISCIPLINE AND ACCOUNTABILITY IS EASY

JOHNNY APPLESEED CULTURE

THE JOHNNY APPLESEED CULTURE

IS THE CONCEPT OF PLANTING MANY SEEDS HOPING THAT SOME WILL FIND THE RIGHT CLIMATE, SOIL, AND CONDITIONS TO GERMINATE

YOU DEPEND ON LUCK AND WISDOM CAN BE VERY WASTEFUL AND

EXPENSIVE BEFORE RESULTS ARE OBTAINED

THE MISSIONARY CULTURE

THE MISSIONARY LEAVES HIS FAMILY, HOME, COMMUNITY, AND

COUNTRY TO HELP FOREIGN COMMUNITIES HIS OR HER MINISTRY OF LOVE INCLUDES A

GREAT DEAL OF PERSONAL SACRIFICE, PARTICULARLY OF BASIC NEEDSSU MINISTERIO DE AMOR LE PERMITE SACRIFICAR SUS NECESIDADES, IN ORDER TO SERVE OTHERS

THEIR HOPE IS OFTEN IN THE AFTERLIFE AND MATERIAL PURSUITS ARE SECONDARY

MAY NOT UNDERSTAND WHY NATIVES FEEL DIFFERENTLY

PREVENTION REQUIRES

MOTIVATION PARTICIPATION GENEROSITY PERSEVERANCE DISCERNMENT LEADERSHIP PUBLIC

RELATIONS

TECHNICAL KNOWLEDGE

MARKETING GOOD

ADMINISTRATION HONESTY DEDICATION TOTAL

COMMITTMENT

THE BASIC NEEDS ARE

FOOD CLOTHING SHELTER PERSONAL SAFETY DREAMS AND HOPE

SECONDARY NEEDS ARE:

TRANSPORTATION EDUCATION OF CHILDRE ENTERTAINMENT FASHIONABLE CLOTHING VACATIONS AND LUXURY

ALTRUISTIC MOTIVATIONS USUALLY ARISE FROM:

THOSE WHOSE BASIC NEEDS HAVE BEEN FULFILLED

IT IS PROBABLY THE MAIN REASON WHY OUR ORGANIZATIONS ARE SO WEAK

THE NATIVE EMPLOYEE

WORKS FOR A LOW SALARY HARDLY MEETS HIS OR HER

BASIC NEEDS IS AFRAID OF THE ULTERIOR

MOTIVES OF THE MISSIONARY IS CONCERNED WITH THE

FUTURE UNLESS:

THE MISSION ACCOMPLISHED

MAY OFFER BETTER TRAINING, A BETTER PROFESSION, AND A BETTER FUTURE FOR HIS LIFE AND LOVED ONES

THEY NEED A GUARANTEE THAT THEIR COMMUNITY AND LIFE IS WORTH THE SACRIFICE

A FAMOUS OPHTHALMOLOGIST ONCE SAID, THAT PEOPLE SEEK YOU AS LONG AS THEY NEED YOU. It is a fatalist statement but quite true.

IT IS FOR THIS REASON THAT WISE PREDECESSORS TAUGHT US THE IMPORTANCE OF CONTINUING EDUACTION AND TEACHING IN ORDER TO RECYCLE THE TALENT

ORGANIZATIONAL ITEMS

MOTIVATION OF EMPLOYEES IS THE KEY TO SUCCESS

THE SCIENCE OF PSYCHOLOGY DESCRIBES THE NEEDS, ATTITUDE, MOTIVATION EQUATION IN MAN

NEED MOTIVATION ATTITUDE

MY WIFE’S NEEDS ARE

DAILY LOVE AND AFFECTION TIME ALONE BY OURSELVES EXPRESSED INTEREST IN WHAT

SHE DOES TO RECOGNIZE WHAT SHE HAS

DONE ACCORDINGLY AND JUSTLY LIBERTY TO CHOOSE AND MAKE

HER OWN DECISIONS

PRIVATE PRACTICE

PRIVATE PRACTICE

IS A NARCISSISTIC CULTURE EVERYTHING REVOLVES AROUND THE

CONFIDENCE , FAME, AND RESPECT FOR A SPECIFIC PHYSICIAN

REMEMBER NARCISSUS WAS BEAUTIFUL, HE ADMIRED HIMSELF, THOUGHT HE DESERVED EVERYTHING, AND WAS NEVER WRONG

NARCISSUS DROWNED IN A POOL TRYING TO REACH HIS OWN IMAGE

IT IS THE PREVAILING ATTITUDE AMONG OPTHALMOLOGISTS AND IT OFTEN COMPETES WITH INSTITUTIONAL CARE

I LEARNED IN COLLEGE THAT:

THE SMART GUYS GOT THE GOOD GRADES, WORKED VERY HARD, PLAYED VERY LITTLE, AND CAME UP WITH THE IDEAS THAT CHANGED THE WORLD

THE OTHERS PLAYED HARD, GOT POOR GRADES, AND MADE THE MONEY TO FINANCE THE IDEAS MADE UP BY THE SMART GUYS

FORMAL vs. INFORMAL CULTURE

THE INSTITUTION WILL TRY TO CREATE THE FORMAL STRUCTURE

THE EMPLOYEES CAN COME UP WITH A COMPLETELY DIFFERENT AND PARALLEL STRUCTURE THAT CAN COMPETE OR EVEN REPLACE THE FORMAL ONE

THIS OCCURS IN ALMOST ALL ORGANIZATIONS AND IT REQUIRES CONSTANT VIGILANCE

EXAMPLE OF WORKING EXTRA HOURS

FUNDAMENTALS OF SELF-EVALUATION

REQUIRES PHYSICAL PRESENCE TO VERIFY ATTITUDES, BEHAVIOURS, INVENTORY, SERVICE, VOLUME, APPOINTMENTS, AND SURGERY

REQUIRES A CONSTANT EFFORT TO IMPROVE THE SERVICE, HEALTHY GROWTH, AND A CULTURE DEPENDENT ON THE SELF-EVALUATIONS

GOOD COMMUNICATION AND VERIFICATION ARE ESSENTIAL

SELF-EVALUATION EXAMPLE

1. CATARACT SURGERY VOLUME GOES DOWN 2. THE COST MAY BE TOO EXPENSIVE, THE RESULTS

MAY NOT BE GOOD, PATIENTS MAY BE MISTREATED, THE WAIT IS TOO LONG. WHAT IS GOING ON?

3. SELF EVALUATION QUESTIONNAIRES CAN B E MADE FOR SUBJECTIVE AND OBJECTIVE DETERMINATIONS OF ALL FACTORS. PATIENTS ARE INTERVIEWED AFTER SURGERY, THE VISUAL RESULTS ARE CHECKED, FLOW ANALYSIS OF THE CLINIC IS DONE ETC.

4. CONCLUSIONS ARE MADE AND MEASURES TAKEN TO CORRECT THE PROBLEM

SELF-EVALUATION OF SURGERY

ALLEN FOSTER PUBLISHED HIS SYSTEM FOR EVALUATING THE RESULTS OF CATARACT

THE VISUAL CATEGORIES ARE DIVIDED INTO I, II, III, & IV. 20/20-20/40, 20/50-20/80, 20/100-20/200, 20/400-NPL

THE CATEGORIES ARE DONE PER PATIENT AND PER EYE

YOU MATCH THE PRE-OP SITUATION WITH THE POST OPERATIVE SITUATION

THE IDEAL IS TO TAKE MOST PEOPLE FROM III AND IV TO II OR I

ANALYZING COSTS OF CATARACT SURGERY

COST OF PRE AND POST OPERATIVE EVALUATION

COST OF DISPOSABLE MATERIALS COST OF OPERATING ROOM SURGICAL FEES COST OF IOL AND GLASSES INDIRECT COSTS(TRANSPORTATION,

TICKETS, FOOD, COMPANIONS, ETC.)

REAL COST

EVALUATIONS MATERIALS OPERATING

ROOM SURGICAL FEES LENS CORRECT. INDIRECT COST TOTAL

US$15 US$65 US$20 US$00 US$20 US$20 US$140

IN SANTO DOMINGO A CATARACT IS WORTH US$140 AT DR.

ELIAS SANTANA THE SAME SURGERY COSTS US$700 IN THE PRIVATE SECTOR

THE CONFLICT CREATED MUST BE FACED AND RESOLVED BY THE INSTITUTION

WE DO NOT OPERATE ON PRIVATE PATIENTS, WEALTHY PATIENTS, OR INSURED PATIENTS. WE ONLY OPERATE ON THE POOR

IF WE BREAK THIS RULE, WE WOULD LOOSE OUR VOLUNTEERS

COMPETITIVE ASPECTS POOR PATIENTS ARE QUITE WELL

INFORMED ABOUT TECHNOLOGICAL ADVANCES. THEY WATCH CNN, DISCOVERY, AND INTERNATIONAL TV

NOT INFREQUENTLY WE GET PATIENTS REQUESTING INTRAOCULAR LENS SURGERY, LASER SURGERY, OR PHACOEMULSIFICATION

YOU MUST BE SENSITIVE TO THEIR EXPECTATIONS OR YOU LOOSE THEIR CONFIDENCE IN THE SERVICE PROVIDED

VISION OF THE FUTURE

CENTERS OF ASSISTANCE TO THE POOR MUST BE MULTIPLIED AND INCREASED

FOR THIS TASK, NEW PROFESSIONALS ARE NEEDED

WE CANNOT WAIT FOR THIS TRAINING TO COME FROM OTHER COUNTRIES, WE MUST TAKE ON THE RESPONSIBILITY AND DO IT OURSELVES

THE IMPORTANCE OF SPECIALIZATION

THE SPECIALIZED PROFESSIONAL MUST DEDICATE HIS OR HER TIME TO THAT FOR WHICH HE/SHE WAS TRAINED

OTHER TASKS SUCH AS SCREENING, FOLLOW-UP, CHECK UPS, FLOW OF PATIENTS, MUST BE DELEGATED APPROPRIATELY

THESE DISCIPLINES INCLUDE:

VISUAL HEALTH PROMOTERS COMMUNITY BASED REHABILITATORS OPTICIANS OPHTHALMIC TECHNICIANS OPTOMETRISTS LOW VISION EXPERTS GENERAL OPHTHALMOLOGISTS OPHTHALMIC SURGEONS ADMINISTRATORS SOCIAL WORKERS

ADMINISTRATIVE TASKS

MATERIALS MANAGEMENT INFRASTRUCTURAL EQUIPMENT ADN

SPECIALIZED INSTRUMENTS HUMAN RESOURCES INCLUDING

TECHS, NURSES, MD’S, ETC. FINANCIAL RESPONSIBILITY

(ACCOUNTING, AUDITING, FUND RAISING PUBLICITY, STATEMENTS, ETC.)

CONCLUDING REMARKS SUCCESS OF THESE PROJECTS DEPENDS

ON LONG-TERM COMMITMENTS PERSEVERANCE OF STAFF APPROPRIATE MOTIVATION CONFIDENCE IN THE SERVICE PROVIDED ECONOMIC INDEPENDENCE CONTINUOUS ,CRITICAL SELF-

EVALUATION AND IMPROVEMENT SPIRITUAL GROWTH