CALIFORNIA STATE UNIVERSITY, NORTHRIDGE
THE ROLE OF THE HOSPITAL ADMINISTRATOR
IN PATIENT EDUCATION
A project submitted in partial sa·tisfaction of the
requirements for the degree of Master of Science in
Health Science, Health Administration
by
Robert Warren Morgenstern
June 1981
The Project of Robert Warren Morgenstern is approved:
Jud th C. Solomon, M.S.H.A., Advisor
I
California State University, Northridge
ii
ACKNOWLEDGEMENT
I am deeply grateful to the members of
my thesis committee, Dr. Jerome Seliger,
Dr. Donald Hufhines, and Mrs. Judith
Solomon, for their patience, guidance
and valuable contributions to this
project.
I also wish to thank the members of my
family and friends who had to put up
with so much from me.
A special thanks
goes to Emily and Rose Palmer, my two
dearest friends.
ii.i
TABLE OF CONTENTS
Page
APPROV'AL. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ii
ACKN'OWLEDGMENT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
iii
LIST OF TABLES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
vii
LIST OF FIGURES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
viii
ABSTH.ACT • . . . . . . . . . . . . . . . . . . . . . . . . .
~
. ... .... .. .... .
ix
Chapter
1.
2.
INTRODUCTION. . . . . . . . . . . . . . . . . . . . . . . . . . . . •
l
Statement of the Problem...............
l
Background for the Study...............
1
Importance of the Study................
3
Need for the Study. . . . . • . . . . . . . . . . . . . . .
3
Delimitations..........................
5
Organization of the Study . . . . . . . . . . . . . •
5
REVIEW OF THE LITERATURE . . . . . . . . . . . . . . . . .
7
SU~RY . .
3.
4.
~
• . • . • . . . . . . . . . . . . . • . ..
18
t-'IETHODOIJOGY . . . . . • . . . . . . . . . . ; . . . . . . . . . . . . .
21
Objectives . • . . . . . . . . . . . . . . . . . . . . . . . . . . .
21
Selection of the Sample................
21
Survey Instrument......................
23
Data Collection........................
25
Data Analysis. . . . . . . . . . . . . . . . . . . . . . . . . .
25
THE MODEL ••••••••••••••••.••••••.••••••••
27
THE NZ1,NAGE.r-1Et.:rr 'l'ECHHIQUE. . . . . . . . . . . . . . . . .
28
..•..•..•••
iv
Chapter
5.
6.
Page
PROGRAM EVALUATION AND REVIEW
TECHNIQUE . . . . . . . . . . . . . . . . . . . . . . . • . . . . . •
30
Background of PERT •..............••.•..
32
NETWORK ANALYSIS •..•.....•...............
33
THE PERT NETWORK •.....•..............•..•
34
Defining the Project •.•......•........•
34
The Activity List ••.•......•...•......•
35
The Network • • . . . . . . . . . . . . . . . . . . . . . . • . . .
35
RULES FOR DRAWING A NETWORK DIAGRAM •.•..•
36
Time Estimates • . . . . . . . . . . . . . . . . . . . . . . . •
39
Rules for Estimating Time ...•.....•...•
41
The PERT Formula • . . . . . . • . . . . . . . . . . . . . . .
42
The Critical Path ••................•...
44
THE MODEL • . . . . . . . . . . . . . . . . . . . . . . . . . . . . • . •
46
Project Objective . . . . . . . . . . . . . • . . . . . . . •
47
F..ES ULTS • . . . . . . . . . . . . . . . . . . . . . . . . • . . . . . . . .
52
Questionnaire Results • . . . . . . . . . . . . . . . . .
53
SUMMARY, CONCLUSIONS AND RECOMMENDATIONS.
65
Conclusions • • . . • . . . . . . . . . . . . . . . . . . . . . . .
69
Recommendations • . . . . . . . . . . . . . . . . . . • . . . .
74/
~p-~-<"
/
//
\..,/''
BIB LI OGHA PI-IY ••••••••••••••••••••••••••••••••••••••
76
.,_qp PE:r.:J"DICES .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • •••
81
A.
Z\ MODEL FOR PLANNING PATIE:t:1T EDUCATION .••
82
B.
THE QUESTIO:t-1NAIRE • . . . . . . . . . . . . . . . . . . . . . . •
104
v
I
Chapter
c.
D.
Page
LETTER AND POST CARD SENT TO
ADMINISTRATORS •••••.••••••••••••••.••••
lll
FOLLOW-UP LETTER •••••••••.••••••••.••••••
114
•
vi
•
LIST OF TABLES
Page
Table
1
.Lo
Response Rate of Potential Respondents .••
53
2.
Classification of Surveyed Hospitals •...•
54
3.
Mean Scores for Items in the Survey •.•..•
55
4.
Respondent Hospitals Having a Patient
Education Program •.................•...
57
Committee Setting General Policy For
All Inpatient Education Programs .....••
58
Personnel with Membership on the
Hospital Committee for Inpatient
Education..............................
59
Department Responsible for Coordinating
Inpatient Education Activities ........•
59
Consultants Used by Hospitals to Plan
Inpatient Education Programs .......... .
60
5.
6.
7.
8.
vii
LIST OF FIGURES
Figure
l.
Page
The Network Diagram. . . . . . . . . . . . . . . . . . . . . •
viii
51
ABSTRACT
THE ROLE OF THE HOSPITAL ADMINISTRATOR
IN PATIENT EDUCATION
by
Robert Warren Morgenstern
Master of Science in Health Administration
The purpose
or this
study was to develop
administrative procedures through which a hospital
administrator could become involved in patient health
education.
Specifically, this direct involvement would
entail his active participation in initiating, organizing,
allocating resources, and helping to put into operation
the American Public Health Association 1 s patient education
model.
Secondly, the Program Evaluation and Review
Technique {PERT) management tool was used to provide a
structured framework of producing a logical and ordered
plan for implementing the program. ··To determine if these
roles were appropriate and feasible, a survey of a number
of hospital administra·tors v.Jas conducted.
ix
The methodology used in this study included the
use of Likert style questions, fill-ins and free answer
questions.
These focused on patient education, the
American Public Health Association's patient education
model, and the use of PERT.
The respondents were drawn from a "deliberately
selected 11 universe of 65 hospital administrators.
This
universe was selected based on the information obtained
from the American Hospital Association's 1979 Guide to
the Health Care Field; and from the specific criteria
for participation developed by the researcher.
The overall results showed that nearly all
respondent hospitals had an ongoing inpatiant health
education program, and one was in the planning stages.
All the administrators expressed an interest in patient
education.
They felt that in their capacity they should
be innovative policy makers; and initiators of medical
care programs to meet the health needs of their
ties.
co~muni­
The administrators were also interested in the
PERT management technique as a potential source for
improving efficiency, productivity and cost containment.
In conclusion, the results further indicated that the
procedures designed for implementing the APHA's patient
education program were feasible in a hospital setting.
X
Chapter 1
INTRODUCTION
Statement of the Problem
This study dealt with the role of the hospital
administrator in patient education.
Specifically,
administrative procedures were developed through which a
hospital administrator could initiate, organize, and help
put into operation the American Public Health Association's
patient education model.
A survey of a number of hospital
administrators was conducted to obtain their ideas and
reactions to these administrative procedures, as well as
to the management tool which was used.
Background for the Study
The primary concern in health care today are its
annual escalating costs.
Since the mid-1960's a
combination of factors (i.e., Medicare and Medicaid laws;
general inflation throughout the American economy;
expensive medical technology; excess demand for health
care; and ou·tright mismanagement of health programs; among
others), created the root causes for the enormous health
care cos·ts we experience today.
In 1977 Americans paid out $162.2 billion dollars
or 8. 8 percent of the Gross National Produc·t. for health
care.
(39: 380)
The Department of Health, Education, and
1
2
Welfare, estimated 1979's health care costs to be $205.8
billion.
(27: 16)
This represents a rise of one million
dollars an hour, twenty-four hours a day, and doubling
every five years.
(10: 22}
On a more personal level, HEW
also estimated that the average family of four paid
$2,115 for medical care in 1978; and can expect to pay
$3,590 by 1983 if nothing is done t.o curb these costs.
(28: 16)
Finally, the Carter Administration projected
that health care costs would rise to about $749 billion
dollars annually by 1990!
(29: 2)
A great share of the blame for these cost increases
can be directly attributed to each person. Victor Fuchs
has stated that:
'l'he greatest current potential for improving the
health of the American people :is to be found in
what they do and don't do to and for themselves.
Individual decisions about diet, exercise, and
smoking are of critical importance, and collective
decisions affecting pollution and other aspects of
the environment are also relevant. (15: 54-55)
Former Secretary of HEW, Joseph A. Califano, Jr., put it
bluntly when he said:
The most important contributors to disease reduction
in America have not been hospitals, expensive and
sophisticated therapeutic techniques, or new
technologies, but rather public health measures
that prevent disease. Indeed, the next dramatic
breakthrough in the health of Americans will probably
be achieved not in the field of acute care, but in
prevention. We need to build prevention efforts into
the very structure of the health care sys·tem, in ways
that: cut across all our programs. (9: 600)
3
Jmportance of the Study
One attempt which is gaining greater momentum at
decreasing rising health expenditures is to teach the
consumer about health prevention, and the proper use and
non abuse of the health care system.
As a result of this
momentum, this study has developed administrative procedures
for use by a hospital administrator to implement a patient
education program.
Furthermore, this study is important for two other
reasons.
First, the hospital administrator becomes
directly involved in the initiation, implementation,
decision-making process and resource allocation for the
start-up of a patient education program.
Second, the
Program Evaluation and Review Technique (PERT) management
tool is used to provide the structured framework of
producing a logical and ordered plan for implementing
the program.
Need for the Study
In making the decision to implement a patient
education program for his institution, a hospital
administrator must be cognizant of a number of important
considerations and factors that affect the health care
of Americans.
Paramount consideration is the need to
understand the "health care system," \vhich is in a
constant state of change.
4
The word system as defined by Johnson, et al., is:
An organized or complex whole; an assemblage or
combination of things or parts forming a complex
or unitary whole. (23 :4)
The study of any system requires an analysis of the input,
transactions and output of the interacting component
parts.
Today, however, it is difficult for the
administrator to differentiate the "health care system ..
from other systems of the society, because health action
is interrelated with all other aspects of the society:
its physical environment, housing, education, nutrition,
lifestyle, the economy, the political structure, and its
religious and philosophical assumptions.
Another important consideration that must be
clearly understood by the administrator is that a hospital
is a system, which consists of a set of subsystems, each
interrelated and interdependent.
All of them must be
managed, coordinated and directed to accomplish the goals
and objectives of the institution.
Rakich and Darr have
noted that:
Portrayed as a system, the hospital resides within
a 11 SUpra-system," which is its external environment.
When viewing the larger supra-system (health care
delivery), the individual hospital with its own
subsystems becomes a subsystem within itself. The
hospi·tal does not exist in isolation, but in a
dynamic environment. It must react to the environment and cope with it. At the same time the
hospital must be aware of its impact on the environment. (34: V)
·
In recognizing that all of these systems make-up
an interrelated and complex whole, the administrator can
5
then design and develop hospital programs and policies
that can properly work for the benefit of all systems
that compose our society.
One such beneficial program is
patient education.
Delimitations
This study was limited to the deliberate selection
of hospitals and their administrators who met certain
established criteria by the researcher for their
participation in the study.
Only hospital administrators
from Los Angeles County participated.
Organization of the Study
The remainder of the.study was organized into
five chapters:
•
Chapter 2 presents a review of all the literature
on cost and resource savings obtained by hospitals which
have a patient education program.
The literature also
discusses behavior modification of patients which have
utilized these education programs.
_chapter- 3 presents the administrative procedures
for developing a hospital patient education program; and
its implementation through the use of the Program
Evaluation and Review Technique management tool.
Chapter 4 sets forth the methodological aspects
of the study.
Chapter 5 presents the results and analysis of
6
the survey data.
Finally, Chapter 6 presents a summary of the
study, the conclusions and recommendations.
Chapter 2
REVIEW OF THE LITERATURE
The literature review focused specifically on how
cost and resource savings were achieved by hospitals when
they conducted a patient education program.
Cost and
resource savings in patient education programs are
infrequently cited in hospital finance literature,
because this topic has not, for whatever reasons, received
serious attention from researchers in the health field.
A computerized Medline search was made, and it produced
only seven pertinent studies •
./'
·. /
..,".1
/
Healy conducted a study of preoperative instruc.
tions on patients at the Good Samaritan Hospital in
Phoenix, Arizona.
(19: 62)
In a period of four months
321 patients were followed through the course of their
hospitalization.
Of these, 181 patients were given
extensive preoperative instructions, and 140 were not.
A specific nursing care plan was devised and used
for each patient in the experimental group the evening
before surgery.
This included instructions about deep
breathing, turning, coughing, body mechanics, and an
explanation of the specific procedures expected '.vith the
patients particular operation.
The study's results showed that of the 181
7
8
patients receiving the special preoperative instructions,
152 had major abdominal surgery.
From this group of 152,
a total of 135 patients went home 3 to 4 days prior to
the expected day of discharge.
In contrast to the control
group of 140 patients who did not receive the intensive
instructions, only 3 patients were discharged before the
anticipated date.
Of the 181 experimental patients, 160
began oral narcotics on the fourth postoperative day
without difficulty, and were off all medication on the
sixth day.
Of the 140 control patients, oral narcotics
were not given to 127 patients until the sixth or seventh
day, and 13 patients were still on parenteral narcotics
on the day of discharge.
/
,J
A study similar to Healy's was condu,czted at the
Massachusetts General Hospital in Boston,\_,,,; Egbert and
associates.
(12: 825)
They randomly assigned 97 patients,
all of whom were hospitalized for elective abdominal
surgery, and divided them into two groups.
The control
group consisted of 51 patients who were not informed
about pos·toperative pain by the anesthetist.
These
patients were given routine care and treatment.
The
"special-care" group consisted of 46 patients and they
were told by the anesthetist about postoperative pain,
how severe it would be, and how long it would last.
These
patients were advised that the pain was caused by spasms
in the muscles under the incision, and that they could
9
relieve most of the pain themselves by relaxing the
muscles.
In order to do this the patients were taught
breathing exercises designed to relax these muscles and
relieve most of the pain; how to turn on their sides
using their arms and legs while relaxing their abdominal
muscles; and how to use the trapeze that was hanging over
the middle of the bed (control patients also had the
trapeze but were never instructed as to its use).
Finally,
these patients were told that if they could not achieve a
reasonable level of comfort, to ask for medication.
Following the surgery, the special-care patients
requested 50 percent fewer narcotics for the relief of
pain than the control group.
Even more important was the
fact that the surgeons, who were unaware of the care each
patient had received, sent special-care patients home an
average of 2.7 days earlier than those who received no
patient education.
\
'
'·j
,~/--
Levine and Britten conducted a study at the Tufts-
/~~""
New England Medical Center in Boston, of 45 male patients
suffering with moderately severe to severe hemophilia A
or B.
(25: 195)
These 45 patients, along with their
immediate family members, were the focus of a special
self-treatment program offered by the hospital.
A brief traning session was conducted on the
theory of hemophilia treatment, the available preparations
.and the complicatiorls of therapy.
Training also consisted
10
of dosage preparation and self-infusion by patients and
some with the aid of their family members.
This was carried
out at the clinic or emergency room under the authors•
supervision.
Home therapy was begun after two to four
medically supervised infusions, the patients ability to
do the procedures, his degree of insight of the disease,
and his self confidence.
Detailed health records of all patients were kept
during the period before the initiation of self-therapy.
Each patient served as his own control, and a comparison
was made between the one year period before starting selftherapy and the one year after self-therapy.
The results showed that 41 patients were either
employed or in school during the
s~udy
period.
This group
had lost 1052 days yearly from work or school (mean, 26.3
days per patient) before self-therapy, as compared with
274 lost days (mean, 6.8 days per patient) afterwards.
This amounted to a decrease of 74 percent in absenteeism
from work or school.
The study group also spent a total
of 432 days yearly as hospital inpatients before starting
home self-therapy (mean, 9.8 days each), and 42 days yearly
thereafter (mean, 0.95 days each).
This represented a
decrease of 89 percent in hospitalization days.
Before
the self-therapy program, these patients visited their
local or hospital physicians 1012 times yearly (mean, 23
times each).
After the program only 242 visits (mean, 5.5
--~~------~~------
------
--
---
-0-=-
11
times each) were made.
This was a 76 percent reduction
in outpatient visits.
A major problem for the hemophilia patient is the
financial aspect of his care.
In the year before the
patients received educational instructions, their average
cost for their illness amounted to $5789 each.
figure, the authors claim is conservative.
This
At hospitals
where each significant bleeding episode is still treated
on an inpatient basis the yearly cost may average twice
this amount or more.
After the home infusion program
was in operation, the patients yearly costs declined to
an average of $3209.
The major beneficiaries of this
45 percent savings were those third-party payers who
covered 80 to 90 percent of the expenses for this group
of patients.
At the Los Angeles County-University of Southern
L,.../',,
Cetlifornia Medical Center, Miller and Goldstein installed
a telephone "hot line" for diabetic patients.
(31: 1388)
This enabled the patients to call in for information,
counseling by physicians and nurses, scheduling of
appointments, and to have prescriptions refilled.
The
success.ful operation of this hot line system depended on
establishing the use of the telephone service by the
diabetic clinic population.
To introduce this telephone
service, all diabetic patients coming to the clinics and
being discharged from the wards were shown how to make
12
full use of the service.
Instruction booklets printed in
Spanish and English, together with the special number to
call, were also given to all patients. To assure patient
access to the diabetes service at all times, a 24-hour,
seven-day-a-week, direct dial, hot line telephone answering
service was established.
The overall results in a two year period, from
1968 to 1970, were enormous.
By 1970 there had been 6900
telephone calls divided evenly among those requesting a
scheduled appointment, those seeking medical advice, and
those requesting a prescription refill.
Visits to the
emergency room for these reasons were virtually eliminated.
In addition to the reduced number of emergency room
visits, a dramatic decline in hospital admissions was
seen.
In 1968 the total diabetic clinic population
numbered 4000, and in 1970 the number had increased to
6000 patients.
In these two years the number of hospital
admissions decreased from 2680 to 1250.
The financial savings obtained by the reduced
number of hospital admissions were very substantial.
Since each diabetic admission averaged 8.3 days of
hospitalization, and at an average all-inclusive daily
cost of $150 {in 1969), each admission cost the County
about $1245.
Therefore, the reduced number of admissions
of 1430 (from 2680 to 1250 in two years) resul·ted in a
savings of $1,797,750.
These numbers clearly show that
13
a great number of admissions were either unnecessary or
preventable.
There were two other benefits directly attributable
·to this program.
First, the hot line averted 2300
patients from visiting the clinic to obtain drugs.
The
cost to the County per visit in 1970 was $46, therefore
a savings of over $100,000 was achieved.
Second, the
incidence of diabetic comas was reduced from 300 in 1968
to less than 100 in 1970.
Rosenberg reports on a special heart disease
project initiated by the staff of the heart and circulatory
program of the New Jersey State Department of Health.
(36: 793)
The project was conducted in cooperation with
St. Peter's General Hospital of New Brunswick, New Jersey,
from 1964 to 1966.
The research design called for 50 patients with
congestive heart failure, and who were outpatients of
St. Peter's General Hospital to be the study group.
Another 50 patients with a similar diagnosis were outpatients at three other hospitals in the state and were
to constitute the control group.
During an observation
period of 1 year, the control patients received normal
clinic care.
The patients at St. Peter's Hospital received
the extensive services of the educationally oriented multidisciplinary team.
This team consisted of the project's
medical director, project coordinator, health educator,
14
public health nurse, diet counselor, hospital·dietitian,
social worker, three medical residents, the associate
director and supervisor of the outpatient department, and
the director of the Visiting Nurse Association.
The team recognized that there would be a certain
lack of validity in comparing outpatients from different
hospitals \vho might not receive comparable care even
though the diagnosis was similar.
Special criteria
therefore, was established as the parameters for comparisons.
These included sex, age, comparable etiology, and
the functional and therapeutic classifications accepted
by the American Heart Association.
Additionally, since
it is a fact that congestive heart failure is a progressive
disease, it was also decided to compare the group's
experience against itself.
That is, to compare an equal
number of days at risk for each patient before and after
his or her acceptance to the project.
The results showed that before the project began
23 study patients were admitted 35 times for congestive
heart failure, and spent 600 days in the hospital.
One
year after the project was implemented only 6 study
patients were admitted 12 times for congestive heart
failure, and spent only 148 days in the hospital.
The project yielded these comparisons between the
study and the control group.
For sixteen months 29 study
patients were matched with 29 control patients in
15
accordance with the established criteria, and were compared for hospital readmission and readmission days.
The
study group had 5 hospital readmissions totaling 82
readmission days.
The control group had 9 patients
readmitted to the hospital and they totaled 238 readmission
days.
The experience of the control group before and
after entry into the project showed an increase in
readmission days from 167 to 238.
This however was not
unexpected because of the progressive nature of the
disease.
From the perspective of the number of hospital
readmissions and the number of. days hospitalized for
congestive heart failure recurrences, significant improvement in the study patient was noted.
The research further indicated that a greater
knowledge of diet, drugs, and the disease itself, offered
by members of the multidisciplinary team as part of the
treatment, resulted in less use of hospital days by study
patients.
The Northwest Kidney Center in Seattle was this
country's first Hemodialysis center, and it was established
in 1962. (6: 20)
According to Blagg, the center's
current primary function is to promote home kidney
dialysis for its patients.
About 80 percent of all the
center's patients are on a home dialysis program, and the
remaining 20 percent receive special dialysis treatments
at the cer.:ter.
16
Since 1962 many dialysis units have been
established around the country in hospitals and small
centers. Dialysis is a critical life saving procedure
and one which is very expensive for the average patient
and his family to afford.
Therefore, Congress in 1973
established under the sponsorship of Medicare the EndStage Renal Disease Program to pay for this dialysis.
Blagg states that in 1978, some 40,000 chronic kidney
disease patients, of all ages, were enrolled in this
program.
Due to the enormous expenses involved with kidney
patients, ·the center has estimated that if half of the
40,000 patients were in a home dialysis program that
$128 million dollars could be saved every year.
After
training a patient and installing his equipment, the
yearly cost of home dialysis supervised by the center can
average $11,566.
The Medicare allowed costs for these
patients is $23,400 yearly. The center's home dialysis
program has therefore achieved a savings of over $10,000
per patient.
This does not include the cost benefit that
may accrue as a result of the home dialysis patient being
rehabilitated.
There are several negative consequences which have
resulted from this Medicare sponsored program. First, the
percentage of kidney patients on home dialysis has dropped
from 40 percent to 11 percent.
In other Western countries
17
the percentage of patients in home dialysis is growing
very fast.
Second, Medicare has made it lucrative for
hospitals and centers to encourage dialysis in an outpatient facility instead of at home.
Physicians also
encourage out-patient dialysis because their reimbursement
is appreciably less for the care of home dialysis
patients.
Laugharne and Steiner report that in 1971 three
hospitals in Toronto, canada, established the Tri-hospital
Diabetes Education Center, commonly referred to as Tridec.
(24: 14)
One of the hospitals serves as the host for this
continuous project where classrooms, offices, laboratories,
and lounges are provided; as well as administrative,
medical and emergency back-up services.
Tridec has recognized the need of the diabetic and
his family to adequately understand the nature of
diabetes mellitus.
In order to achieve such a goal, the
diabetic has to assume an active and participating role.
To accomplish this, Tridec has physicians, nurses,
dietitians, and social workers available to help the
diabetic assume this responsibility.
The center presents
a comprehensive four day program to the patient which
includes all medical and dietary aspects of the management
of diabetics.
In late 1976, Tridec sent out questionnaires to
each of the 247 physicians who had referred patients to
18
the center ·that year.
More than half (54 percent) of the
referring physicians replied, representing 436 patients
out of 709 registered in 1976.
The information obtained
showed that 1652 inpatient hospitalization days were
avoided by Tridec registrants in that period.
At an
average daily rate per patient of $150, a total savings
of $24 7, 800 v.1as achieved in 1976.
Statistics collected between 1973 and 1976 showed
that hospitalized Tridec patients were discharged earlier
than non Tridec diabetic patients.
In this three year
period, a total of 1686 inpatient hospitalization days
were saved.
In 1976 alone, this savings amounted to 500
hospital days, or $79,500.
Summary
In summation, the literature suggests that there
were a number of ~~~~!:~-!:~~!-...~~£~. Q§~~Y§<:l ...f.J.:Q.m...P..9.t.i~n:t .......
~-==~Ee<;:~t~.2!!~,.E.;:g_g_r;~E!!.~M.J::l;!.g,j::.
heal·th centers
~-
o
were conducted at hospitals and
These were:
Most of the patients who had undergone major
abdominal surgery were discharged from the ·
· - -.. _,~,-.,_.~>=<_,.,.,__. ..... ~,~¥~-·"
~-~··"""'·~·-~"L'•"•
hospital between 2.7 and 4 days earlier than
\vas normally anticipated.
2.
There was
a minimal and a reduced use of
'---·--------drugs by patients after surgery.
'----~-~-~···--·-·
19
3.
A faster recuperation and a convalescence with
fewer post-operative
complicat~Q!l§ __ was
... -"""'.......,.,.....~~~...,.......,...,-,.,.,
~-~,_.._,..,.
obtained
-··
by patients.
4.
There was a reduced number of hospital
readmissions and readmission days for patients
with chronic illnesses (specifically,
hemophilia, congestive heart failure, and
diabetes).
5.
Persons with a chronic illness lost less time
from work and from school.
6.
The programs taught those individuals who
suffered from a chronic illness how to live
with, and to take responsibility for their
illnesses.
This responsibility manifested
itself with the person learning how to
administer his own medications, adhering to
his dietary regimen, and to deal with his
physical activities.
7.
The seven programs cited in this literature
review accounted for millions of dollars in
savings to third-party payers and to patients,
as hospital admissions, clinic, physician,
and emergency room visits were
prevente~
The results obtained from these studies are
important because they reinforce the belief that by
20
educating a patient and having him practice health
prevention, lives, health resources, and money are
saved.
Chapter 3
M.ETHODOLOGY
This chapter describes the methodology employed
in the study including the sampling strategy, the survey
instrument, data collection procedures, and the analysis
and interpretation of the data obtained.
Objectives
This project had two objectives.
The first, was
to develop administrative procedures using the Program
Evaluation and Review Technique management tool in
implementing the American Public Health Association's
hospital patient education model.
Second, 1t1as to have a
selected group of hospital administrators determine, via
a survey instrument, if the administrative procedures
developed for the APHA's patient education model were
feasible: and if the model could be implemented in an
actual hospital setting.
Selection of the Sample
The sample in this study represented a deliberate
selection. Fox stated that a "deliberate selection" was
a process whereby the x:esearcher directly and deliberately
select:ed specific elements of the population to be his
invited sample.
(14:340)
The initial step in identifying
21
22
and obtaining this sample was to consult the 1979 edition
of the American Hospital Association•s Guide to the Health
Care Field.
(2: A-26)
This publication contains the names
of all the hospitals in the United States, and each is
separated by state and county in which they are located.
Other relevant information includes the following:
1.
The address, telephone number and hospital
administrator are given.
2.
The different accreditation bodies are listed
(i.e., Joint Commission on Accreditation of
Hospitals, American Medical Association, and
so forth) •
3.
The facilities of the institution are indicated
(i.e., X-ray department, intensive care unit,
etcetera) .
4.
The type of an institution that it is (government hospital, nongovernment not-for-profit,
investor owned, or Osteopathic).
5.
The type of service hospital (i.e., general
medical and surgical, obstetrics and gynecology,
psychiatric, etcetera).
6.
The final categories deal with such hospital
data as the number of beds in the institution,
admissions and births per year, personnel and
the yearly operating expenses.
23
Based on the data provided by the Guide, the
researcher was able to select sixty-five hospitals
required for the deliberate sample.
Certain criteria
was established in selecting the sample.
1.
These were:
The hospitals had to be located in the Los
Angeles area.
This was due in case any
administrator had any inquiries about the
chapter or questionnaire sent to him.
2.
Only hospitals which had between 6 and 299
beds were chosen.
3.
All hospitals were to be accredited by the
Joint commission on Accreditation of Hospitals.
4.
The hospitals chosen were short-term stay
medical and surgical facilities. Specialty
institutions such as orthopedic, psychiatric,
childrens, and others were not considered.
5.
The three types of short-term stay hospitals
selected were the community supported, the
church operated (both not-for-profit), and
the investor owned (for-profit).
All govern-
ment hospitals, both federal and non-federal,
were excluded from this study.
Survey Instrument
The hospital administrators who agreed to
participate in this study were each sent a copy of
Chapter 3 of this project.
Based on this plus additional
24
research information, a survey questionnaire was formulated.
The questionnaire was first submitted to all three project
advisors for their evaluation.
Questions were revised for
the final questionnaire version and sent out to the
participating administrators.
The questions used in the survey instrument
(Appendix B) were divided into two categories.
The first
category contained the structured questions for which an
objective score was obtained by means of a Likert scale.
Another group of questions was also designed for structured
response, where several
opt~ons
were given plus a chance
to add answers not on the list.
The questions in category two explored the feelings
and views of the respondents.
Since the researcher did not
know what kind of answers to expect, the queries left the
respondent free to offer any idea or ideas he wanted.
answers were left open, unlimited, with no alternatives
offered; and the respondents used their own words.
Questions were asked such as, what the administrators
believe their role should be in the implementation and
support of a patient education program.
Would the
proposed model of administrative procedures allow for
the
~PEA's
patient education program to be implemented
in a hospital setting.
Finally, what were the opinions
of the administrators towards PERT, and with regard to
The
25
its potential widespread implementation on all types of
projects and programs within their hospitals.
Data Collection
The survey data was obtained in the following
manner:
1.
A letter plus a stamped self-addressed return
post card (Appendix C) explaining the research
and their solicitation to participate in this
study was sent to sixty-five hospital
administrators.
2.
Those administrators agreeing to participate
in the study were sent a copy of Chapter 4
•
of this project, the outline of the APHA
model (Appendix A) , and the questionnaire
{Appendix B).
Included in the packet was a
stamped self-addressed return envelope for
the questionnaire and the chapter.
3.
A follow-up letter
(Appendix D) and the same
questionnaire were sent to several participating administrators who had not returned their
survey packet after a period of 6 weeks.
Data Analysis
The questionnaire was divided into two parts.
In
. part one ·the items were constructed with a five point
~ikert
scale, with responses ranging from strongly agree
/
/
26
to strongly disagree.
The responses were used to place
the respondents on an .. attitude continuum" for each
question asked.
The researcher decided that a high scale score
would mean a favorable attitude.
Therefore, in scoring
these questions the respondents were asked to put a check
mark along one of the five positions.
So if the answer
to one of the questions was strongly agree, the number 5
was checked off on that question, and so forth.
Having
scored each item from 5 to 1, all items were then added
to obtain a total score.
Since there were ten questions the possible range
of total scores was from 50 (SxlO) to 10 for each
respondent.
A score of 35 is thus a little above the
midway point towards the positive end of the scale.
This
would tend to confirm our belief that PERT and patient
education was supported by administrators.
The other questions included in part one required
a "yes .. or "no," and fill-in answers.
These were
tabulated and the results described.
The responses from the free answer questions in
part tvm were analyzed, and a description of the results
given.
Chapter 4
THE MODEL
It was determined at the outset of this thesis
that the model developed by the American Public Health
Association for planning a patient education program
would be used.
This model was developed by the APHA's
committee on Educational Tasks in Chronic Illness.
The Committee states that their model:
is a mechanism for defining the educational process
necessary for patient and family education and may
be used for any illness regardless of its etiology
or chronicity. It can be used by physicians, nurses,
social workers, health educators, and others
responsible for planning and organizing educational
programs for pa~ients and their families. (38: 4)
The authors describe their model as a "step-by-step
procedure representing a comprehensive and interdisciplinary approach to analyzing educational needs of patients
in a variety of settings." (38:7)
The presentation of the model, which appears in
Appendix A, shm'ls the interrelationships of the process
of patient education.
Although the discussion of each
step provides a rather straightforward statement of what
to do, the implementation of the procedures requires a
t.remendous amount of understanding of educational
methodology.
A great deal of preparation and experience
is required in selecting and using appropriate methods
"7
L..
28
to collect
data~
analyze it, and creatively design effec-
tive measures to achieve the desired goals, and to
institute feasible and productive evaluation measures.
This stage of program development is perhaps the crucial
place where a patient education coordinator is needed,
or consultation from an experienced expert in educational
methodology.
However, the model does not present any actual
administrative procedures which are necessary in order to
implement this model.
In discussing the model, the
Commi,ttee has treated very lightly what is an enormous
leap from the broad outline of procedures to evolving
specific plans for program operation.
The report states
that to implement the model effectively, consideration
must be given to the following:
1.
The situations and opportunities for
accomplishing the steps, including the
"how, " "by whom, " and "when";
2.
The necessary staff attitude, knowledge, and
skills; and
3.
The required administrative arrangements,
policy decisions, and resources. (38:7-8)
As the reader can clearly discern, these are very
general statements of what is required to implement the
model.
The purpose of this thesis therefore, is to suggest
a model procedure for a hospital to follow in implementing
the
APa~'s
patient education model. To do so we will be
29
aided by the use of the Program Evaluation and Review
Technique.
· THE MANAGEMENT TECHNIQUE
Today's unrelenting demand by consumers for
increased health care services, is forcing many hospitals
to develop new health programs or projects to meet these
needs.
The possible future enactment of a National Health
Insurance system portends an even higher level of use in
the already limited health care resources available in
this country.
As a result, the hospital administrator,
who is aware of these problems, is either by choice or
design personally becoming involved in coordinating and
directing many of these new programs or projects.
The
efficient and effective implementation of such programs
or projects is crucial; for if these fail to attain their
objectives as a result of inept planning, programming and
control, a double expense is incurred for the organization.
Not only are the resources which are directly allocated
to the program lost, but the organization must also pay
the cost of the lost opportunity in terms of other programs
for which the resources might have been better used.
Because of the complexities involved in operating
these new programs/projects, the administrator is forced
to separate himself from matters of detail, and to deal
only vlith the broader aspects and problems these programs/
projects may encounter.
Therefore, he is forced to think
30
and act only in generalities because he lacks the techniques or management tools which would allow him to see
and understand the entire operation in complete detail.
He does not always know which activities are critical
and require special attention. . He also may not know what
effects a delay or failure in one activity will have on
others following it, or on the success of the program/
project as a whole.
What is needed is a master plan
which will provide the administrator and h.is supervisors
with an up-to-date picture of the program or project at
all times; and which would f·ollow a uniform system
understood by all.
Because management has recognized a
need to address these factors, a number of management
tools have been developed.
One such tool is the Program
Evaluation and Review Technique (PERT) .
The usefulness
of PERT will be outlined in the following pages.
PROGRAM EVALUATION AND REVIEW TECHNIQUE
PERT is a management tool for defining and
integrating events which must be accomplished on a timely
basis to assure completion of program objectives on
schedule.
It is a technique for focusing management•s
attention on danger signals requiring remedial decisions#
and on areas of effort that require trade-offs of time,
resources, or technical performance so that the capacity
to meet major deadlines may be improved.
(22: 5)
31
The following points are also attributes of the
PERT system, and these are as follows:
1.
PERT is designed to aid the manager in planning
and controlling one-of-a-kind or few-of-a-kind
projects, such as in the defense, aerospace,
commercial and construction industries.
One time
only health programs can benefit from the PERT
system.
2.
As a management control tool, PERT demonstrates
the complex interrelationships of a large number
of activities.
These activities form an
integrated network of events, and their completion leads to the project's end objectives.
(23: 251}
3.
The PERT system is a set of planning and control
techniques designed to help the manager in
budgeting, estimating, controlling the schedule,
cost, and technical performances required to
achieve the project's objectives.
4.
It requires management to plan in a uniform and
logical manner.
5.
(22: 5)
(20:12)
It provides management with an approach for
keeping planning up to date as the project's
work is accomplished, and as conditions change.
(17: 46)
6.
Management is quickly able to foresee the impact
32
of any variations from the plan, and to take
corrective action in anticipation of trouble
spots rather than after the fact.
7.
(26: 260)
PERT allows management to simulate the effect
of alternate decisions under consideration, and
to study their effects upon the project deadlines,
prior to implementation.
8.
(22:6)
PERT can be applied to small and simple projects,
and not solely to large and complex ones.
9.
(32: 17)
PERT provides management with information about
the project's resources that are not being fully
utilized.
On many occasions, the unused or
underutilized resources can be applied to other
parts of the project which may otherwise be
delaying activity or project completion.
(13:6)
Background of PERT
PERT was created to answer an important need for
improved planning and control in the United States Navy's
Polaris missile project.
Under the auspices of the Navy
Special Projects Office and their representatives, the
Lockheed Aircraft Corporation, and the management firm
of Booz, Allen and Hamilton, they developed and first
applied PERT to the Polaris missile project in 1958.
This
was an extremely complex project, involving research,
development, design and manufacture of totally new systems
and devices.
The PERT technique was an overwhelming
33
success and saved the Navy two years over the scheduled
delivery date of its Polaris missile system.
PERT is partially evolutionary and partially a
new creation.
It draws upon Gantt charting, line of
balance, and milestone reporting systems--long familiar
to management.
(32:7)
PERT has also drawn from the network
analysis concept, and this has become the key ingredient
in this technique.
The time and cost concepts, the
critical path, and progress reporting system are basically
new creations.
Merger of the evolutionary and the new
has resulted in a much improved approach to management
planning and control.
NETWORK
Al.\fALYS.IS
The successful achievement of a project's objectives requires a plan that identifies specific tasks to
be achieved in sequence, based upon specific interdependencies among these tasks.
Such a plan is at the very
heart of the Program Evaluation and Review Technique,
and it is called network analysiso
The network used in PERT may be defined as being
"a system, with subsystems, where the various segments
interconnect and interact at one or more points." (23:
244-45)
Each separate segment, or link, of the system
is explained with regard to the other components or
activities of the system.
This clearly demonstrates the
total system and the interrelationships among the parts.
34
Network analysis achieves its purpose in three
broad steps.
First, it illustrates to management and its
personnel in diagrammatic form a picture of all the
project's activities which need to be performed.
Second,
it considers the limitations imposed by the availability
of personnel, funds, material resources, and, in view of
these, estimates the time required to do each job.
Third,
it applies the estimated job time to the network diagram
and then analyzes the network.
Analysis in this case
means the calculation of the total length of time involved
in each path through the network.
In order to accomplish these steps it is necessary
to understand the composition of the network used in PERT.
The network concept is basically a simple technique, and
we shall now see how it functions.
THE PERT NETWORK
Defining the Project
Before the PERT network can be developed and
implemented, two important steps must be undertaken.
The
first, is for everyone concerned to know what the project
is together with its objectives.
Were it not for the fact
that this requirement is so often overlooked, the statement
might be regarded as trite; unfortunately, it needs to
be made.
At some level of management, some individual or
committee must initiate and approve the project; define
35
what it is; and determine its start and end points.
Decisions must also be made on such factors as scheduled
dates, requirements of other departments, the availability
of personnel, funds, materials, equipment, space, and the
myriad of other details related to the project.
The Activity List
The second step is to prepare a detailed list of
all project tasks or activities to be accomplished.
The
list is compiled by those individuals who will be directly
involved in carrying out the project's activities.
Such
a list is very useful to the planning team in discussing
the organization's available resources, and project
responsibilities.
The list also serves as a reference
•
for networking.
The Network
The PERT network consists of three basic components
--events, activities, and logical interrelationships.
An
event is a clearly identifiable point in time which marks
the beginning or completion of a specific activity in the
project. An event does not consume time or resources,
and is shown on a network diagram as a square, circle,
or some other geometric design. Synonymous words with
events are "node" and "connector." (44: 172)
An activity is the time and resource consuming
work effort required to complete a specific segment of
36
the total project.
(23: 254)
Each activity is categorized
by having a specific starting event, and an ending event.
(4: 16)
The activities in the network are graphically
represented as arrows which join these events.
Commonly
used terms synonymous with activity are "task" and "job."
In a network an event and an activity are shown as follows:
ACTIVITY
A network therefore, is composed of a number of
events related to one another by activities.
The network
starts with a single beginning event, expands into a
number of paths which connect events, and finishes with
a single end event which terminates the project.
The most important characteristic of a network,
however, lies in the logical interrelationships between
events and in the representation of these on network
diagrams.
The emphasis on strict logic is one of the
principles of networking introduced by PERT.
As a result
of this discipline planners are forced to think about
their project in a thorough and analytical manner.
(32: 25)
RULES FOR DRAWING A NETWORK DIAGRAM
In order to properly construct a network a
number of rules must be observed.
l.
Every network must have only one point of entry,
the start event, and one point of emergence,
37
the end event.
2.
(5: 20)
Each activity is shown by a single arrow and
it must have definite starting and ending points.
The tail of the arrow marks the beginning of the
activity, and the head of the·arrow indicates
the end of the activity.
ACTIVITY
FINISH
START
The lengths of the arrows in the network diagram are of
no significance.
However, the flow of arrows in a network
must go from left to right.
3.
The arrows in the network imply logical precedence
only.
Therefore, an event cannot occur until
every activity preceeding it has been completed.
Also, an activity succeeding an event cannot be
started until the event has occurred.
The follow-
ing examples are based on the logical precedence
rules:
Example A
Activity a must be completed before
activity b can begin.
0
a
.ot-----·
.
~-----
b
Example B
Activity a must be completed before the
38
event can occur; and then activities b
and £ can begin.
a
Example
c
Activities
~
and b must be completed before
the event can occur; and then activity £
can begin.
c
Activities a and b are not required to be
completed simultaneously, but must be
finished before the event can occur.
4.
i<'lhile drawing a network the PERT user must
continually ask these questions.
a.
(13: 22)
What events and activities must be
accomplished before this event can occur?
b.
What events and activities cannot be
accomplished until after this event is
completed?
c.
What events and activities can be
accomplished concurrently?
39
5.
Number the network events so that the numbers
increase as one goes from the start to the final
event.
caution must be taken to avoid using the
same number on two separate events.
An example
is presented to illustrate the numbering, and how
the events are read.
Event
Activity
1-2
=
Wash instruments
2-3
=
Sterilize instruments
There are several other network rules which
correspond to projects which are so large that they
require a computer.
There will be no explanations
offered here of these rules, because only a consultant
with expert knowledge and understanding of PERT and the
computer can put them into operation.
Time Estimates
PERT is used for projects where there is a great
deal of uncertainty about how long any given activity will
take.
Therefore, once the logic and detail of the network
have been established, the next step is to obtain an
estimate of the elapsed time required to accomplish each
activity.
All time computations are made prior to the
performance of the activity.
The PERT planner can obtain
40
these times from those individuals who have the responsibilities for doing the work the activities represent.
(13: 27)
Most frequently these are supervisors, contractors,
training directors, the individual worker, and others.
In making time estimates, one is asked to call on his
general experience; his knowledge of the requirements of
the activity in question, and to consider the personnel
and facilities available to him.
(41: 13)
The time forecast consists of three individual
estimates per activity:
optimistic time (a), most likely
time (m), and the pessimistic time (b).
These three
estimates form the basis for determining the uncertainties
involved and the probability that expected events will
occur as
pl~nned.
These duration time estimates can be
revised periodically to reflect actual expenditures or
changes in the rate of time use. {40: 6)
1.
Optimistic Time (a) • This is the shortest
possible time in which the activity can be
completed in an ideal environment; and where
the activity will not encounter complications
or unforeseen difficulties. (27: 100) The
rule of thumb is that there should be only one
chance in a hundred of accomplishing the
activity in less than this time. (21: 140)
2.
Most Likely Time (m). This is the length
of time that would occur most often if the
activity were repeated many times exactly
under the same conditions. (18: 34) This
estimate should take into consideration normal
circumstances, making allowances for some
unforeseen delays, and should be based on
the best information available. {13: 24)
41
3.
Pessimistic Time (b). This is the longest
time the activity could ever take assuming
that everything goes wrong, and that all of
the possible setbacks and or delays occur.
This does not include natural calamities,
labor strikes or other highly unusual
catastrophes. A rule of thumb is that there
should only be one chance in a hundred that
the activity would require more time than
the pessimistic time. (13: 24)
Rules for Estimating Time
The PERT user must observe another set of simple
rules in making the three time estimates.
1.
One of the most important rules in estimating
activity times is that they must not be influenced by the
time available to complete the project.
(21: 142-43)
Failure to adhere to this would completely invalidate the
PERT probabilities, and
destro~
any positive contribution
that they may make in the planning function.
Time
estimates should be revised only when the scope of the
activity is changed, or when the facilities and manpower
assigned to it are changed.
2.
(32: 285)
Equally as important, is not to expand or to
reduce time estimates in order to fit expected dollar
budgets and arbitrary schedules.
(4: 81)
To insure that rules one and two are met, two
techniques are used to prevent estimators from thinking
in terms of calendar dates.
a.
These are:
"Jumping around." As this technique implies,
it requires that time estimates for activities
be made in different parts of the network in
42
a completely random fashion, instead of
estimating the activities which are placed
in a logical order. (21: 143)
b.
To withhold the scheduled or contractual
dates until all time estimates have been
performed.
3.
The possibilities of natural calamities or
unanticipated catastrophes should not play any role in
determining time estimates.
4.
biased.
It is essential that time estimates not be
When dealing with department managers and other
supervisory personnel, the PERT system must be fully
explained to them. Furthermore, they must be made to
understand that the time estimates are just that, and
not absolute firm schedules to which they are committed.
(21: 143)
The PERT Formula
When a planner uses three time estimates, he
derives from them a single value to represent the expected
activity duration time.
This is found by using a simple
formula:
te:
a + 4m + b
6
In the formula, the expected time derived is represented
by the symbol te; and the optimistic, most likely, and
pessimistic time estimates by a, m and b respectively.
It must be noted that the expected time, as the name
43
implies, is what one would expect the activity duration
to be on the average if the activity were repeated a
large number of times.
However, with most PERT applica-
tions activities usually occur just once, and therefore
are not repeated a large number of times. But te is still
the best estimate one can make of the time required for
a single occurrence of an activity. {43:43)
All time estimates in the network calculations
are based upon "elapsed time"--days, weeks, months, etcetera.
These are the times required for the performance
of an activity from beginning to end.
Any one of these
units may be used, but once chosen, the same unit must be
applied to all of the calculated results in the network.
The expected time estimate (te), is written on the network
diagram directly above the appropriate activity.
Finally, to illustrate all of these concepts the
following example is offered.
A PERT planner has obtained
from his personnel three time estimates for one particular
activity in the project.
The estimated times are:
optimistic (a) is 5 weeks, most likely (m) is 7 weeks,
and pessimistic (b) is 9 weeks.
All that the planner
must now do is to simply place these numbers that correctly
correspond to the letters in the formula, and to compute.
Thus:
te:
a + 4m + b
6
44
te:
5 + 4{7) + 9
te:
7 weeks
3
42
6
Using the resulting value, the planner can be reasonably
certain that the activity time will be 7 weeks.
On the
network diagram the time estimate would be shown in this
way:
7
ACTIVITY
EVENT
EVENT
The Critical Path
Once the events, activities and times have been
decided, the network diagram can be drawn.
Then one of
the most important parts of constructing a PERT network
occurs.
The
11
critical path .. is determined ..
The concept of network paths is a key fundamental
in the PERT approach.
Network paths lay the basis for
management action to improve project or program performance.
A path may be defined as a chain of sequential events and
activities required to move from a start point of a project
to its completion.
network.
There are a number of paths in a
Work may be carried out, as required, along
each path--separately and concurrently.
(30: 137)
In a very simplified network shown below there
are three paths.
One includes events 1, 2, 3, and 4.
Another includes events 1, 2, and 4; and the third includes
45
events 1, 3 and 4.
From a management point of view, a
significant difference exists between these paths.
As has
been mentioned, each path may be worked on concurrently.
Carried to its logical end, this means the longest elapsed
time path through the network governs the length of the
entire project.
If management wishes to assure completion
on schedule or to shorten the project, this longest path
must be the center of focus for actions to be taken.
For
this reason, this path is called the critical path.
Path
1
Total Time
2
3
Type
4
29
Critical
Semi-Critical
1
2
4
20
1
3
4
9
Slack
If we assume that management does take action to
shorten the critical path, then another path in the
network may become critical.
The next path or paths
likely to become critical have been termed semi-critical.
There will be some paths in the network which
will be much shorter in elapsed time than others.
These
are paths where management may be able to borrow resources
46
for application against the critical path.
For this
reason, such paths have been termed slack paths.
The management implication of the path concept
can now be observed.
By identifying the various paths in
the manner mentioned, it is clear to which path management
should devote its attention for over-all control of the
project, and from which paths it may likely borrow
resources.
It is also evident which paths are next likely
to come under management scrutiny.
This portion of the chapter has sought to explain
the philosophy of PERT and its rudiments.
The next
sequence in this chapter actually puts PERT into action.
THE MODEL
The
AP~'s
patient education model demands that
in order for the educational tasks to be accomplished,
the health facility administrator must:
provide a favorable climate, adequate manpower,
resources, and time to carry out each step. An
important first step would be to employ a trained
and experienced educational consultant, or health
educator, to serve as the coordinator of the patient
education program. Other important factors include
the provision of conference room space, the development of administrative mechanisms which allow for
an exchange of information among staff, and the
provision of specialized consultation and evaluation.
(38: 4)
In developing the administrative procedures necessary
to carry out the APHA's program, we make a number of
assumptions:
47
1.
That the model will be implemented in a
hospital with 299 beds or less.
The latest available
figures from Hospital Statistics (1979), published by the
American Hospital Association, shows that 83.3 percent
of all acute care hospitals in this country have between
6 and 299 beds. (3: 8)
2.
That the activities contained in the PERT
diagram are those which would meet the necessary administrative requirements of institutions with 299 beds or less.
· 3.
It is assumed that the Patient Education
Coordinator will be hired from outside of the hospital,
instead of the Nursing department.
4.
That certain key Medical and Nursing Staff
members are receptive to the idea of an education program
for
patients~
and that their support and influence will
help to get it started among their colleagues.
Project Objective
The objective of this project is for the Administrator of ABC Hospital to establish administrative requirements necessary to develop, implement and operate an
inpatient health education program.
The following pages will contain the events,
activities and expected times of the project; and this
will be followed by the PERT network diagram in Figure 1.
EVENTS
ACTIVITIES
EXPECTED TIME
(in weeks)
1-2
Administrator develops an initial proposal
for planning a patient education program by
conferring with key Medical and Nursing
Staff personnel.
1
2-3
Administrator meets with as many Medical
Staff members as possible to propose the
program.
4
2-4
Administrator meets with supervisory
nursing personnel (Head Nurses, supervisors,
Team Leaders) •
2
3-5
Medical Staff approves the proposed program.
1
4-5
Nursing Staff approves the proposed program.
1
5-6
Administrator, Director of Nursing, Personnel
Director meet to discuss the hiring of a
Patient Education Coordinator and health
educators. Job descriptions must be written
out.
1
6-7
Publicize job openings for Patient Education
Coordinator and Health Educators in nursing
magazines, newspapers, etcetera.
4
6-8
Administrator, Controller and Director of
Nursing meet to set up a cost center and initial
budget to hire the Coordinator.
1
~
co
ACTIVITIES
EVENTS
EXPECTED TIME
(in weeks)
7-9
Interview and hire a Patient Education
Coordinator.
2
8-9
Cost Center established and funds are
budgeted for the coordinator and staff.
1
9-10
Coordinator selects and hires the patient
education staff.
2
9-11
Administrator, Patient Education Coordinator,
and Director of Nursing meet with department
heads and key Medical and Nursing Staff
Personnel.
1
10-12
No Activity.
0
11·-12
Form an interdisciplinary Patient Education
Committee. This is to be composed of the
Administrator, Physicians, Nursing, and the
Department heads.
2
12-13
Patient Education Committee meets to decide
what education programs they want to
implement. · (Examples: heart disease,
diabetes, etc.).
2
13-14
Accumulate all available materials on the
designated program(s) .
(From libraries,
commercial agencies, physicians, etcetera).
6
13-15
Reserve rooms for teaching, and obtain
audiovisual and other materials pertinent
to the program(s).
1
~
l.i)
EVENTS
ACTIVITIES
EXPECTED TIME
(in weeks)
14-16
Prepare teaching plans, and adapt the
APHA model.
3
15-16
Train staff to teach the program.
1
16-17
Implement the program by having physicians
sign up their patients.
2
(J1
0
FIGURE 1
NETWORK DIAGRAM
The numbers in the parentheses
signify the expected time for
each activity.
...
........
CRITICAL PATH
SEMI-CRITICAL PATH
IJI
1-'
...
CHAPTER 5
RESULTS
The findings reported in this chapter contain data
resulting from a survey of hospital administrator attitudes
and ideas.
out.
A total of eleven questionnaires were mailed
Eight administrators responded.
The data from these
respondents v1ere assessed and are reported here.
The
survey consisted of ten Likert style questions, plus fillin and free answer questions.
These focused on patient
education; the American Public Health Association's patient
education model; and the use of the PERT management tool
for helping to implement the APHA model.
The survey
instrument along with explanatory material was sent to the
hospital administrators.
The respondents were
dra~
from a "deliberately
selected" universe of 65 hospital administrators.
This
universe was selected based on the information obtained
from the American Hospital Association's 1979 Guide to
the Health Care Field; and the specific cri't.eria for
participation developed by the researcher and cited
earlier in Chapter 3.
The table below indicates the
response rate from this group.
It shows that 36
administrators {55.4%) stated that they could not
participate in the study; 18 (27.7%) fail€d to respond
52
53
completely to the request for their participation; and only
11
(16.~/o)
indicated that they would participate.
Ultimately, however, from this group of 11, only 8
administrators (12.3%) agreed to participate by answering
and returning the questionnaire.
TABLE 1
RESPONSE RATE OF POTENTIAL RESPONDENTS
(%)
Number
Administrators declining to participate
36
(55.4)
Administrators failing to respond
18
(27.7)
Administrators completing survey
8
(12.3)
Administrators not completing survey
3
{4. 6)
65
(100)
Totals
Table 2 shows the classification of the 8 respondent hospitals in terms of being profit and non-profit
institutions.
The tab1e further reflects the size of these
hospitals which range from small {85 beds) to medium
(241
beds) institutions.
Questionnaire Results
The questions used in the survey instrument were
divided into two categories.
composed of two parts.
The first category was
The first consisted of ten
questions using a five point Likert scale.
Part two had
54
TABLE 2
CLASSIFICATION OF SURVEYED HOSPITALS
Hospital
A
Classification
Beds
Not-for-Profit
184
B
II
II
II
201
c
II
II
II
212
Investor Owned (for profit)
D
85
E
II
II
II
112
F
II
II
II
126
G
II
II
II
139
H
II
II
II
241
questions which were designed for structured response,
not on the list.
questions.
category two had three free answer
The survey instrument is included in
Appendix B.
The Likert scale was selected for this study
because as Oppenheim has observed:
The Likert scales tend to perform very well when it
comes to a reliable, rough ordering of people with
regard to a particular attitude. Apart from their
relative ease of construction, these scales have
two other advantages:
first, they provide more
precise information about the respondent's degree
of agreement or disagreement, and respondents usually
prefer this to a simple agree/disagree score.
Second, it becomes possible to include items whose
manifest content is not obviously related to the
attitude in question, so that the subtler and deeper
ramifications of an attitude can be explored.
(33: 141)
55
The Likert scores obtained from the respondents,
along with the mean item scores as shown in Table 3,
reflect a degree of agreement by the respondents with the
various variables presented in the survey.
The overall
mean for each of the items is 4.175 on a five point scale.
TABLE 3
MEAN SCORES FOR ITEMS IN THE SURVEY
Item
Mean
1
4.25
2
4.50
3
4.25
4
4.125
5
4.375
6
4.125
7
4.00
8
3.875
9
3.75
10
4. 50
Based on the responses cited in Table 3 plus the
Likert scores, the answers indicated the following:
1.
The administrators felt that they must be
innovative policy-makers responsible for
initiating medical care programs to meet
health needs.
56
2.
An administrator planning and developing health
care programs must have a comprehensive social
view of the community he is endeavoring to
serve.
3.
Hospitals can help reduce health care costs
through patient education programs.
4.
Each American is going to have to rely on
himself and be responsible for maintaining
his good health.
5.
By educating the consumer, health care costs
can be reduced by not overutilizing health
resources.
6.
A joint effort by the hospital and health
consumers in deciding what health education
programs are needed, strengthens the
community's commitment to these programs and
to health prevention.
7.
Management techniques used in the different
industries of the American economy should be
applied to hospitals.
A hospitalwide use of
a management tool such as PERT can be a
source for cost containment.
8.
The application of PERT has the potential for
improving efficiency and productivity from
hospital personnel.
57
9.
It is necessary that information and feedback
be obtained from hospital operations in order
for proper administrative decision-making to
take place.
Another group of questions was designed to obtain
a structured response.
There were various options given,
and the respondent was allowed to add any answers that
were not on the list.
The first question asked of these 8 administrators
was whether or not their hospitals had an inpatient
education program. Table 4 shows that 7 had one, and another
indicated that theirs was in the planning stages.
This
particular hospital only answered this question in this
part of the survey.
The following answers to the remaining
questions therefore, are from the other 7 respondents.
TABLE 4
RESPONDENT HOSPITALS HAVING A
PATIENT EDUCATION PROGRAM (N=8)
Ongoing Program
7
In Planning Stages
1
In question number two the 7 administrators
indicated that a certain committee set the general policy
for all inpatient education programs conducted at their
institutions.
Table 5 shows that these committees included
the Executive Committee (3 hospitals) , the Patient
58
Education Committee (2 hospitals), the Medical Education
and Audit Committee, and the Educational Services Committee
one hospital each.
TABLE 5
COMMITTEE SETTING GENERAL POLICY FOR ALL
INPATIENT EDUCATION PROGRAMS {N=7)
Name of committee
Executive committee
3
Patient Education Committee
2
Medical Education and Audit Committee
1
Educational Services Committee
1
The committees were multidisciplinary in their
composition.
All of them were made up of physicians,
nurses, and the administrator.
Other personnel with
membership on most but not all of these committees
included the health educator, the social worker, the
dietitian, and medical records.
Multidisciplinary
membership reflects a commitment to patient education as
an appropriate function of all direct care providers.
As a multidisciplinary/multidepartmental activity,
patient education requires both multiple input for goal
attainment, and interdepartmental management support for
the implementation of programs.
59
TABLE 6
PERSONNEL VliTH MEMBERSHIP ON THE HOSPITAL
COMMITTEE FOR INPATIENT EDUCATION (N=7)
Physicians
Nurses
Administrator
Health Educator
Social Worker
Dietitian
Medical Records
The answers to question number 3 revealed that all
7 hospitals had designated a department to coordinate all
inpatient education activities.
(See table 7)
The line
responsibility for this coordination went to the departments of Education (4 hospitals), and Nursing (3 hospitals).
TABLE 7
DEPARTMENT RESPONSIBLE FOR COORDINATING
INPATIENT EDUCATION ACTIVITIES (N=7)
Education
4
Nursing
3
In 6 of the 7 hospitals someone from within these departments was given the specific task of coordinating all the
inpatient education activities.
to these coordinators were:
The various titles given
the Inservice Director and
60
Patient
Coordinator~
Director of Inservice
Education~
Director of Education; Inservice Coordinator; and the
Director of Health Education.
However, none of these
persons devoted all of their time solely to the coordination of inpatient education at their respective hospitals.
The final question in this particular segment dealt
with outside consultants helping to plan a hospital's
inpatient education program.
Only 2 of the 7 hospitals
had such an arrangement with a consulting firm.
TABLE 8
CONSULTANTS USED BY HOSPITALS TO PLAN
INPATIENT EDUCAT.ION PROGRAMS (N=7}
Hospitals using consultant
•
Hospitals not using consultants
2
5
In category two of this survey, the 8 administrators
were asked to express their own opinions and ideas on three
free answer type questions.
There were no restrictions or
alternatives presented, and the respondents used their own
words.
Only 6 of the 8 administrators answered these
questions.
concise.
The answers that they gave were short and
A composite of these answers follows.
The first question asked the respondents what they
thought their role ought to be in implementing and supporting a patient education program.
having several roles.
They saw themselves as
First, they wanted to carefully
61
select a coordinator who would be delegated the responsibility for planning, directing and .implementing a patient
education program.
They wanted this coordinator to operate
the program within the given allocations of space, manpower
and resources that would be provided.
The administrators also saw their role as being
that of a facilitator.
By this, most indicated that they
would have to furnish the new program with strong financial
support; along with encouragement and back-up, especially
when approaching the Medical Staff.
The duties of the
facilitator 1tlould include the coordination of the different
hospital departments, generating community enthusiasm for
the program, and to provide the necessary guidance that
only an administrator could give.
In question number two, the administrators endorsed
the proposed administrative procedures designed by this
project for implementing the APHA' s modeL
However, some
of the respondents added several cogent comments.
One
administrator said that the cost of implementing this model,
as this project proposes, could be financially prohibitive
for facilities with less than 100 beds.
Also, facilities
operating at low occupancy rates would find this program
expensive.
This project was designed with the assumption that
a permanent patient education coordinator and a staff of
health educators would need to be hired from outside the
62
hospital, and not from within the Nursing department.
According to the APHA's model however, a trained and
experienced educational consultant or a health educator
could serve as the coordinator of the patient education
program.
(38:4)
The APHA model and this project's
administrative procedures are very flexible to suit the
specific needs of any hospital.
Another administrator wanted even more time to be
allocated to the procedures to insure that every aspect of
the APHA model would be covered.
In the last question, the administrators indicated
that they were favorably receptive to PERT, but some also
expressed reservations for its implementation hospitalwide.
The administrators recognized PERT as a potentially valuable
resource.
If it is taken seriously by program designers
and users, PERT could be a useful management tool.
It
could also be used for diagnosing the causes and the extent
of a problem, but that it is up to the staff to take action
on the basis of results.
PERT was also praised for putting
programs on a conceptualized time framework. But, one
administrator had doubts about the effectiveness of putting
physicians into any type of time framework.
Finally, PERT was cited as being complex, and this
complexity requires management expertise.
This complexity
say the respondents, could limit its hospitalwide
implementation, and the achievement of cost containment
63
sought from programs and projects.
The only effective way
of dealing with this potential problem is for PERT to be
taught to all levels of hospital management.
The truth
of the matter is, once the essential components of PERT
are mastered, anyone can successfully use this tool for
any program or project on any level of hospital management.
Chapter 6
SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS
This study dealt with the role of the hospital
administrator in patient education.
The study developed
specific administrative procedures through which a hospital
administrator could initiate, organize, and as a facilitator help in the decision-making process of implementing
and operating the American Public Health Association's
patient education model.
In order to test the feasibility of implementing
these administrative procedures, a survey of a number of
hospital administrators was conducted.
The survey
instrument was also designed to obtain reactions and
ideas from the respondents on patient education7 and on the
Program Evaluation and Review Technique (PERT) management
tool that was used in this project.
PERT was used to
provide a structured framework for producing a logical
and ordered plan of the procedures for implementing the
APHA model.
The sample in this study represented a
selection ...
11
deliberate
That is, the researcher directly and deliber-
ately selected specific elements of the population to be
his invited sample.
Once the criteria for participation
in the study was established; the administrators were
64
65
chosen from the American Hospital Association's 1979 Guide
to the Health
c~re
Field.
Of the 65 administrators
identified as potential respondents, only 8 ultimately
answered the questionnaire.
The survey instrument was designed to obtain answers
through a Likert scale, structured responses plus fill-ins,
and by three free answer questions.
The most important
findings of the study were that:
1.
The administrators felt that they should be
innovative policy-makers.
As such this would
require them to have a broad social perspective of their communities in order to plan
and initiate medical care programs to meet
health needs.
2.
•
In supporting a patient education program
the administrators would be required to perform
several roles.
First, is to carefully select
a Coordinator to work directly with the
administrator.
The coordinator would be
responsible for planning, directing, and
implementing a patient education program,
within the given budgetary and manpower
constraints.
Second, and perhaps the most
important role, would be that of a facilitator.
The administrator as
"facilitator" would mean
giving strong financial support for a
66
fledgling patient education program; encouragement and back-up; guidance and helping to
generate hospital and community support for
this new program.
3.
Americans will have to rely on themselves to
achieve and maintain their own good health.
Disease prevention will mean doing without
the bad habits people generally enjoy-overeating, too much drinking, drug abuse,
sexual promiscuity, wreckless and fast driving
habits, cigarette smoking, to name just a few.
At a minimum, individual responsibility will
require the special efforts of exercizing
regularly, going to the dentist, a healthful
diet, and submitting to screening examinations.
4.
Educating and involving the community in
health education strengthens their commitment
to these programs, and to health prevention.
5.
The use of PERT and other management techniques, widely used in most American
industries, should be applied in hospitals.
6.
The administrators participating in this
study approved the procedures designed in this
project for implementing a patient education
program.
67
7.
The literature review has shown that patient
education programs save lives, scarce health
resources and money.
Some of these survey findings are supported by the
literature.
The first finding correlates with Brown's
suggestion that the role of the professional hospital
administrator is:
Largely as a policy-maker, an innovator, and an
initiator of medical care programs to meet health needs.
He is a program-planner and program-developer with a.
broad social role in the total community.
Such a professional orientation stresses hospital
objectives related, ~n most instances, to the solution
of overall community health problems. Further, it
means that the professional hospital administrator must
have convictions of his own concerning the distribution
and organization of medical care services in the
society. No occupational group can hope for professional status if it merely executes the ideas of
others--it must have values which are shared by its
members and are at the same time socially useful.
More specifically, it is likely that the professional
hospital administrator's conceptualization will
encompass social as well as medical care needs,
preventive as well as rehabilitative care, long-term
and psychiastric as well as short-term acute services,
and so on. In short, his concern is for comprehensive, high-quality care for all people in the
community. {7: 20)
In displaying this "outward" view of his community,
the administrator must also look to within his organization
for the actual development and growth of programs.
Toward
this end the administrator is attributed the important role
of "facilitator" or change agent.
Kovner (in Georgopoulos)
has characterized this role in this way:
68
A change agent is more likely to be effective as a
facilitator rather than as a director. The administrator, because of his training, position, and responsibilities, is for many hospitals the person most
qualified and most likely to act as change agent.
Because of increased specialization, changing technology, and increased expectations of consumers and
non-physician employees, hospitals require increased
coordination and organizational adaptability. The
administrator's expertise is that of an integrator
structuring the perceptions among producers, and
between producers and consumers so that change can
be effected without destroying organizational integration. The administrator requires authority appropriate
to his responsibility. Some administrators can gain
sufficient authority to influence hospital effectiveness through successful performance as facilitators
and integrators, and as a result of increased demands
from the hospital's public for changed goal priorities
and higher levels of achievement. (16: 373)
The APHA patient education model is an ideal
example of how an administrator can facilitate the development and implementation of this program.
Tre third finding of this project dealt with
Americans having to rely on themselves for maintaining
their own good health.
In 1979 a report to this effect
was issued by the Surgeon General's office.
The report's
central theme was that the health of this country's
citizens can be significantly improved through actions
individuals can take themselves; and through actions
decision-makers in the private and public sectors can take
to promote a safer and healthier environment for all
Americans at horne, at work and at play.
The report
concluded by saying that:
For the individual often only modest lifestyle changes
are needed to substantially reduce risk for several
69
diseases and many of the personal decisions required
to reduce risk for one disease can reduce it for
others.
Within the practical grasp of most Americans are
simple measures to enhance the prospects of good
health including: elimination of cigarette smoking;
reduction of alcohol misuse; moderate dietary changes
to reduce intake of excess calories, fat, salt and
sugar; moderate exercise; periodic screening (at
intervals determined by age and sex) for major disorders such as high blood pressure and certain cancers;
and adherence to speed laws and use of seat belts.
(42: 10)
The final point dealt with health institutions
educating and involving their community in health education.
The 1976 Task Force on consumer Health Education
identified hospitals, HMO's, Kaiser-Permanente, the
Veterans Administration, and clinics as centers where
health education of the community was taking place
nationwide.
(37: 20-21)
CONCLUSIONS
le
Patient education programming at the
institutional level must take into account the following:
the audience toward whom efforts will be directed; the
specific character and structure of the institution; and
factors facilitating or constraining action.
(11: 4-5)
All of these considerations will influence the direction
and scope of patient education services.
The audience for discussion of patient education
includes the facility's key decision makers: the
facility's management staff, the chiefs of clinical
and administrative services, and the board of
trustees. The persons have to be convinced of the
70
need, the feasibility, and the impact of comprehensive patient education services. (11:4)
Considerations of the institution's character and
structure include the following:
(a)
Institutional characteristics--size,
physical structure, location, and
financial structure; affiliations with
educational institutions, especially
medical and nursing schools; degree of
complexity of organizational structures;
membership in a multi-facility system;
(b)
Management characteristics--degree of
administrative control; patterns of
decision-making; interdepartmental
communication, and collaboration;
tolerance for change or innovation;
presence or absence of incentives for
educational activities;
(c)
Health services characteristics--primary
vs. tertiary; ambulatory vs. inpatient;
specialized vs. comprehensive; or
combination of these;
(d)
Client characteristics--specific population groups (children, veterans, etc.);
residents within a geographical service
area; members of a specific occupational
group (union workers, students, etc.);
71
(e)
Resource characteristics--level of
existing support for educational
activities (personnel, space, equipment,
funds); potential for future allocation;
access to educational resources of other
agencies.
In any health institution there will always be a
number of facilitating or constricting actions that will
exert pressures sometimes competing or conflicting on
health care policy decisions.
That is, a variety of
factors will either permit or deny the development of
patient education services.
For example, health care
administrators face the major dilemma of having to be
responsibletodemands for expanded services, yet simultaneously forced to maintain strict cost control measures.
All the considerations at all three levels are not easily
reconciled. But they do provide a framework for developing
a health care facility plan for patient education.
2.
As hospital administrators and their personnel
become more involved in complex planning for budgets,
building construction, future patient care programs,
personnel education, and so forth, they also become aware
that effective planning is an urgent need.
Program
Evaluation and Review Technique is designed for such
situations.
advantages:
The utilization of PERT provides the following
72
a.
It requires the identification of goals
(as in management by objectives).
b.
It necessitates the ordering and recording of events, and development of
timetables.
c.
It demonstrates how scarce resources
are best allocated: and what specific
responsibilities are assigned to the
staff.
d.
It necessitates the development of
criteria for evaluation of progress.
e.
It helps in the identification of
variables that must be considered.
f.
It involves others in the development,
implementation and evaluation of
programs, assuming that participatory
management is an integral part of the
philosophy of the organization.
g.
If the participants are knowledgeable
and objective, utilization of the
technique should greatly reduce the
errors made in planning and should be
an aid in rational decision-making.
It is very easy to believe that PERT is the panacea
health planners have always looked for.
It is not a
73
panacea.
The success of any health program is and will
continue to be dependent upon wise and sound decisions,
and not on a management planning tool.
3.
Today, there is ample evidence that millions
of Americans do want and are seeking additional health
information, guidance, and assistance in adopting a healthy
lifestyle that is so relevant to their individual problems
and concerns.
One needs only to see how successful the
multi-million dollar business in do-it-yourself health
literature, drugs, vitamins, "health foods," and the
various behavior modification techniques and movements are
thriving. As Ray Brown has pointed out:
The United States has become a health conscious
nation whose health aspirations have kept ahead of
medical advances and whose health sense is becoming
as sophisticated as the activities behind the "no
visitors" sign in the inner sanctums of the hospital.
(8: 71)
To further expand and promote this better health
concept, the role of the consumer has sharply come into
play.
The consumer movement has left little doubt that
demand for public participation in decision-making in
health policy, as in other fields, is steadily growing.
Rakich, et. al., maintain that:
Consumers must be brought into the mainstream of
decision-making concerning their health care services
and the institutions that provide them. Health care
providers must develop a depth of social responsibility that will be measured in part by involving
consumers in the major decision-making roles in our
health care system. (35: 38)
74
The hospital administrator must recognize that
health education and consumer participation are inseparable.
The same reasons that lead hospital administrators to an
interest in health education should lead them invariably
to an interest in consumer participation.
Consumer
involvement in hospital based health education programs
is a natural and feasible way to start the process by
which they must become involved in other aspects of
hospital planning and management.
RECOMMENDATIONS
1.
Patient education should be an integral part
of a patient's hosP,italization treatment regimen.
In
I
order to achieve effective curative and or therapeutic
results among hospitalized and out-patients, a carefully
planned and organized patient education program should be
developed within a hospital.
The size of a program would
need to vary according to the institutions bed size, and
the financial, medical and personnel resources available.
2.
The Program Evaluation and Review Technique
should be taught and used by all hospital management
personnel.
The use of this tool can be successfully used
for almost any activity or project in the hospital.
3.
Costs for patient education that are an
integral part of patient care are currently reimbursable
by third-party payers. Blue Cross Plans; the Health
Insurance Association of America, representing health
75
insurance companies responsible for 85 percent of health
insurance; and Medicare; all now reimburse a hospital's
patient education program for costs integral to the
treatment of a patient's illness or injury.
(1: 2)
/
A hospital may also institute its own method of
funding and paying for a patient education program.
This
could be done through daily billing charges, billing
for the educational services rendered, or through gifts
/'
I
and grants.
4.
This study should be conducted on a statewide
level and again on a local level.
In order to obtain a
be·tter response rate, a selected number of local area
hospitals, and adhering to the participation criteria,
would be personally visited by the researcher.
If
permission were granted by the prospective institutions,
then a more comprehensive and in-depth survey on patient
education could be designed.
A statewide survey could be carried out in the
same manner as this project was done.
This study there-
fore, would be strengthened because a statewide view of
patient education would be obtained.
Also of interest
would be the administrators ideas on PERT; and the
implementation procedures of the APHA's patient education
model.
,.,//
--.,__ ,./
BIBLIOGRAPHY
76
BIBLIOGRAPHY
1.
American Hospital Association Center for Health
Promotion.
"Financing Inpatient Education
Activities." San Francisco, California: Second
Annual National Symposium on Patient Education,
October 20-22, 1978.
(Mimeographed.)
2.
American Hospital Association. Guide to the Health
care Field.
1979 Edition. AHA Catalog No. 2451.
Chicago, Illinois, 1979.
3.
American Hospital Association. Hospital Statistics.
1979 Edition. AHA Catalog No. 245lm. Chicago,
Illinois, 1979.
4.
Archibald, Russell D., and Richard L. Villoria.
Network-Based Management Systems (PERT/CPM).
New York: John Wiley and Sons, 1967.
5.
Battersby, Albert.
and Scheduling.
1970.
6.
Blagg, Christopher R.
"Home Dialysis Program costs
Less Than Outpatient Treatment," Forum, 2, No. 1
(January/February, 1978), 20-25.
7.
Brown, Douglas R.
"A New Administrative Model for
Hospitals," Hospital Administration: Quarterly
Journal of the American College of Hospital
Administrators, 12 (Winter, 1967), 6-24.
8.
Brown, Ray E.
"The Hospital Redefined," Hospital
Progress, 47, No. 11 (November, 1966), 71-73.
9.
Califano, Jr., Joseph A.
"Prevention in Health Care.
An Agenda for the Next 100 Years," Public Health
Reports, 93, No.6 (November-December, 1978),
600-601.
10.
Carter, Jimmy.
"State of the Union Address," Los
Angeles Times, January 24, 1979.
11.
Deeds, Sigrid G., Barbara J. Hebert, and Joan M.
Wolle. A Hodel for Patient Education Prograrnming.
Public Health Association. Washington, .February,
1979.
Network Analysis for Planning
New York: John Wiley and Sons,
77
12.
Egbert, Lawrence D., and others.
"Reduction of
Postoperative Pain by Encouragement and Instruction
of Patients," The New England Journal of Medicine,
270, No. 16 (April 16, 1964), 825-827.
13.
Evarts, Harry F. Introduction to PERT.
Allyn and Bacon, 1964.
14.
Fox, David. The Research Process in Education.
York: Holt, Rinehart and Winston, 1969.
15.
Fuchs, Victor R. Who Shall Live? Health, Economics,
and Social Choice. New York: Basic Books, 1974.
16.
Georgopoulous, Basil S. Organization Research on
Health Institutions. Ann Arbor: University of
Michigan Press, 1972.
17.
Goldmeier, John, and C. Alex Alexander.
"General
Systems and PERT Concepts in Community Mental
Health Planning," Maryland State Medical Journal,
24, No. 1 (January, 1975), 46-50.
18.
Hartung, L. P., and J. E. Morgan. PERT/PEP:
A Dynamic Project Control Method. New York:
Space Guidance Center, 1961.
Boston:
New
FSD
19.
Healy, Kathryn M.
"Does Preoperative Instructions
Make a Difference?" American Journal of Nursing,
68, No. 1 (January, 1968), 62-67.
20.
Hoare, H. R.
Analysis.
21.
Horowitz, Joseph. Critical Path Scheduling. Manaqement Control Through CPM and PERT. New York:
Ronald Press, 1967.
22.
Iannone, Anthony L. Management Program Planning and
Control with PERT, MOST and LOB. New Jersey:
Prentice-Hall, 1967.
23.
Johnson, Richard A., Fremont E. Kast, and James E.
Rosenzweig. The Theory and Management of Systems.
New York: McGraw-Hill, 1973.
24.
Laugharne, Elizabeth, and George Steiner.
"TriHospital Diabetes Education Centre," canadian
Nur~, 73, No. 9 (September, 1977), 14-17.
Project Management Using Network
London: McGraw-Hill, 1973.
78
25.
Levine, Peter H., and Anthony F. H. Britten.
"Supervised Patient-Management of Hemophilia," Annals of
Internal Medicine, 78, No. 2 (February, 1973),
195-200.
26.
Littlejohn, Jr., Preston A.
"The Use of PERT in
Preparing for Accreditation Review," Journal of
Dental Education, 38, No.5 (1974), 259-266.
27.
Longest, Jr., Beaufort B. Management Practices for
the Health Professional. Virginia: Reston Publishing, 1976.
28.
Los Angeles Herald Examiner, March 20, 1979.
29.
Los Angeles Times, May 16, 1980.
30.
Martin, charles c. Project Management: How to Make
it Work. New York: American Management
Association~ 1976.
31.
Miller, Leona v., and Jack Goldstein.
"More Efficient
Care of Diabetic Patients in a County-Hospital
Setting," The New England Journal of Medicine,
286, No. 26 (June 29, 1972), 1388-1391.
32.
Moder, Joseph J., and Cecil R. Phillips.
Management with CPM and PERT. 2d ed.
Van Nostrand Reinhold, 1970.
33.
Oppenheim, A. N. Questionnaire Design and Attitude
Measurement. New York: Basic Books, 1966.
34.
Rakich, Jonathan S., and Kurt Darr. Hospital
Organization and Management. 2d ed. New York:
Spectrum Publications, 1972.
35.
Rakich, Jonathan s., and others.
"Facilitating
Change," Hospital and Health Services Administration, 22, No. 4 (Fall, 1977), 36-49.
36.
Rosenberg, Stanley G.
"Patient Education Leads to
Better Care for Heart Patients," HSMHA Health
Reports, 86, No. 9 (September, 1971), 793-802.
37.
Sommers, Anne R., ed. Promoting Health. Consumer
Education and National Policy. Maryland: Aspen
Systems, 1976.
38.
U. S. Department of Health, Education, and Welfare.
A Model for Planning Patient Education. Health
79
Project
New York:
Resources Administration. HEW Publication No.
(HRA) 76-4028. Washington: Government Printing
Office, 1972.
39.
u. s.
40.
u. s.
41.
U. S. Department of the Navy. PERT Summary Report
Phase 2. Special Projects Office, Burea of Naval
Weapons. Washington: Government Printing Office,
1961.
42.
u. s.
43.
Weist, Jerome and Ferdinand K. Levy. A Management
Guide to PERT/CPM.
2d ed. New Jersey: PrenticeHall, 1977.
44.
Wren, George R. Modern Health Administration.
Athens: University of Georgia Press, 1974.
Department of Health, Education, and Welfare.
Health, United States 1978. Public Health Service
Publication No. (PHS) 78-1232. Washington:
Government Printing Office, 1978.
Department of the Navy. PERT Summary Report
Phase 1. Special Projects Office, Bureau of Naval
Weapons. Washington: Government Printing Office,
1962.
Surgeon General of the Public Health Service.
Healthy People. The Surgeon General's Report on
Health Promotion and Disease Prevention. Public
Health Service Publication, No. 79-55071.
Washington: Govemment Printing Office, 1979.
80
APPENDICES
81
APPENDIX A
A MODEL FOR PLANNING
PATIENT EDUCATION
82
Introduction
This is a report of the Committee on Educational Tasks in Chronic
Illness, which was appointed in 1968 by the Public Health Education
Sectiqn of the American Public Health Association, to determine
the. educational components in caring for the chronically ill after the
acute stage of the illness.
Basic Premises
The Committee accepted the following statements as a basis for its
work:
1. Children and young adults as well as older people suffer with
chronic illness.
2. Patient education is an integral part of patient care.
3. Target groups to be considered in educational programming include:
a. the patients and their families;
b. staff members (at all levels) in the health care setting; and
c. appropriate groups in the community.
4. The team approach, with the physician serving as the team leader
and coordinator, offers the most effective approach to patient
education.
5. Since various disciplines-e.g., occupational therapy, physical
therapy, social service-may have different educational goals,'the
patient education program must be carefully reviewed and coordinated.
6. Consideration should be given ·to an "educational prescription''
that would be available in written form and would accompany the
patient as he moved from one facility to another.
7. All those involv.ed in caring for the chronically ill have need tor
in-service and continuing education.
Committee Assignments
Initially subcommittees were established which related to the .setting
in which care is provided to the chronically ill patients. Although the
Committee was cognizant that this arbitrary division was not ideal, it
was considered preferable to other kinds of divisions such as disease
or age categories. Subcommittee chairmen were encouraged to approach the assignment creatively and to include representation from
several disciplines on their committees.
3
83
The task of developing the report was further complicated· by the fact
that a meeting of the entire group could not be arranged. However, in
October 1969 a preliminary report was circulated to the subcommittee
chairmen for comment.
One subcommittee postulated a model which has been modified as
presented on pages 7 to 8. This model has served as the basis for
this final report.
The Model
The model, developed by the Committee, is a mechanism for defining the educational processes necessary for patient and family education and may be used for any illness regardless of its etiologY, or
chro,nicity. It can be used by physicians, nurses, social workers, health
educators, and others responsible for planning and organizing education programs for patients and their families.
To accomplish the educational tasks described in this booklet, the
health facilily administrator must provide a favorable climate, adequate manpowP.r, resources, and time to carry .out each step. An
Important first step would be to employ a trained and experienced
educational consultant, or health educator, to serve as the coqrdinator of the patient education program. Other important factors include
the provision of conference room space, the development of administrative mechanisms which allow for an exchange of information
among staff, and the provision of specialized consultation and evaluation.
Also, there would be a need for providing opportunities for training
appropriate staff to sharpen its existing skills or acquire new ones; or
modify existing practices so that the patient wilt be helped to utilize
the educational opportunities available. Some of the staff skills require
an ability to:
·
1. Identify what the patient and family need to know and understand
to carry on a prescribed program;
2. Determine through various methods the patient's attitudes, knowledge, and life style;
3. Determine a patient's perceived need for knowledge and hidden
fears;
4. Perceive educational opportunities;
5. Understand and be able to use the educational techniques, Including group discussion; and ·
6. Choose areas and methods of evaluation.
4
84
To implement the steps set forth in the model, it is suggested that
consideration be given to estabhshing two committees to advise the
educational coordinator. One, a medical advisory committee, would
provide an effective communication link to those in the medical community responsible for organiiing and coordinating patient care.
Another, the patient education advisory committee, would sarve as the
bridge not only to the various departments of the facility but also to
the community. In addition, a patient advocate or advisory group
could provide additional feedback. Through these committees. the
coordinator would be in the unique position of being able to obtain
feedback and provide information relative to the educational needs at
patients from the viewpoint of medicine, nursing, other allied health
disciplines, and the community.
The purpose of patient education is, of course, an improved health
!:latus for the patient. The model is not an end in itself but rather it is
a means by which patient and family education can be reached in a
health care facility.
Sincere appreciation is expressed to the members of the Committee
and its subcommittees, representing many disciplines, agencies, and
organizations and working in many areas at the United States.
Joan M. Wolle, Chairman
5
85
Planning for Patient
Education
An essential component of health care is the education of the patient,
his family, and others concerned with his well-being. To achieve
optimum results through the education process, all facets of care
must be coordinated, beginning with the initial medical and social
consultation ahd continuing through all phases of the case. This
coordination, both within and among the institutions serving the patient, must be such that those involved in any one phase of care can
take full advantage of the knowledge, skills, and resources of others
in the health care complex. Thus, the specialized knowledge of many
health professionals can be applied in a way which contributes maximally to quality total care for each patient.
In planning for the educational aspects of health care, consideration
must be given to three groups:
1. Patients and their families;
2. Staffs of institutions serving the chronically ill; and
3. Target populations in the general public.
Factors to be considered In developing a plan for patient education
include:
1. The patient's response to a particular disease or combination of
conditions;
·
2. The patient's unique physiological and psychological makeup,
past experiences, and physical and social environment;
3. The treatment regimen;
4. The staff and others involved in his care;
5. The environment in which the care is given ..
6
86
An educational plan should be developed lor every patient and should
be reassessed periodically since the patient's educational needs
change depending upon such factors as his medical condition, his
knowledge, attitudes, and abilities. Similarly, the educational needs
of the patient's family should be diagnosed individually and assessed
and modifieq periodically.
Staff education is a prerequisite to effective patient education. Planning for staff education is a process in which goals are set, educational
methods and resources chosen, and evaluation defined. Staff education requirements may include training directed at rehabilitation philosophy and organization, program administration, human relations,
group process, the team approach, leadership development, problem
solving, decision making, consultation techniques, and communication skills.
Community education is another important consideration which affects
patient education. Educational efforts among target populations of
the general public should be directed toward:
1. Preventing and limiting illness;
2. Increasing the acceptance, support and app.ropriate use of facilities and health programs and facilities; and
3. Recruiting, training, and retaining needed personnel.
The Model
A model was developed which presents a step-by-step procedure,
representing a comprehensive and interdisciplinary approach to
analyzing educational needs of patients in a variety of settings. The
model delineates five steps:
1. Identification of the educational needs of the patient and family;
2. Establishment of educational
objectiv~s;
3. Selection of appropriate educational methods;
4. lmpl.ementation of the educational program; and
5. Evaluation.
Virtually every effective plan for health education includes these five
aspects which, of course, cannot be considered as separate distinct
steps but as an interrelated process. To implement the model effectively, consideration must be given to:
1. The situations and opportunities for accomplishing the steps, including the "how," "by whom," and "when";
7
87
2. The necessary staff attitude, knowledge, and skills; and·
3. The required administrative arrangements, policy decisions, and
resources.
This model can be adapted easily for use by various health professionals and can be used in planning for a patient or group of patients
in almost any selling such as in hospitals, long-term care facilities,
health centers. anc1 in the home. The model also can be used by personnel to he:ghten their awareness of the educational process as it
relates to patients and their families, and to help staff assess their
individual in-service and continuing education needs. In addition, it
can be usef:.JI in determining the activities of various levels of specialists who h~ve responsibilities for education. The following Is a
discussion of each of the five steps in the process.
88
Step 1-ldentify the
Educational Needs of
Patient and Family
Education of the patient is an integral part of patient care, shaped by
the particular illness. the needs of the individual, the nature of the
prescribed treatment regimen, and skill of the personnel who are
providing care. All personnel responsible for providing patient care
need to understand the patient education process.
Identifying the patient's educational needs begins with a recognition
of the uniqueness of the individual determined by his biological and
psychological makeup, his social and physical environment, and his
past experiences.
These factors account for the broad range of differences existing
among patients in terms of their knowledge of· medical conditions,
understanding of medical terminology, their attitudes toward healih
and illness, the treatment regimen, the social and cultural variations
In response to illness as well as attitudes toward physicians, nurses,
and other health professionals who are providing care in hospitals and
other medical facilities.
Patient education requires knowledge of the disease or illness, resources, and treatment regimen; an understanding of the patient, his
background, and environment: and the ability to have the patient
perceive ways in which he can realize his full potential.
The physician and other health professionals should determine specifically what knowledge and skills the patient and family will need to
obtain maximum benefit from medical care. These goals serve to
establish a common understanding of the aims of patient education for
all personnel involved in his care.
As useful as these goals are, however, they do not provide the. health
professional with a knowledge of what the patient already knows about
his illness and treatment; what misconceptions he may have that could
affect his response to care: hb fears and attitudes toward care; or the
skills or resources he has which could help in treatment. Such information can be obtained only from the patient and those having a close
relationship with him.
9
89
Sufficient information about the patient is seldom acquired during a
single interview or encounter, but rather through a mutual relationship
built upon undeistanding and trust. The educational aspects of care
are a responsibility shared by all personnel who have direct or indirect
contacts with the patient. A basic problem in patient care is that of
obtaining his cooperation in carrying out the prescribed· treatment
plan.
Step II- Establish
Educational Goals
for Patient and Family
The treatment goals serve as a basis for a patient education plan. The
health professional must determine what the patient already knows
about his illness and treatment, the misconceptions he has which may
affect his response to care, his fears and attitudes, or the resources
he has which will help him in the treatment regimen.
'In identifying educational needs, the type of information all patients
need to know about a specific illness should be considered. For example, patients with congestive failure would need to know the reason
for administering digitalis, the problems involved with over- or underdigitalization, and the possibility of a sodium-restricted diet. Thus,
In setting goals, it is important to consider whether the patient already
knows the reason for digitalization, the potential for over- or underdigitalization. and how much he already knows about a sodium-restricted diet. Information lacking in any of these areas should be
provided to the patient.
Data may be obtained by having all personnel involved in the care of
the patient share information in case conferences. After a decision is
made regarding the deficiencies in the patient's knowledge and his
potential for rectifying them, an educational prescription should be
written aimed at providing information to the patient so that he can
accept and carry out the treatment plan.
10
90
Patient education is a continuing and evolving process with responsi. bility for specific aspects delegated to appropriate personnel. Those
responsible for his care need to use data from such sources as the
medical history and interviews as well as from conversations and
observations of the patient and lhe family. The patient should be asked
about the care he is receiving, ·ways in which he feels he is advancing
toward the treatment goals, and his ideas on aspects of care in which
he wants special emphasis or help.
The specific educational goals must be communicated to all concerned-patient, family, and staff-and understood and accepted if
change is to occur.
Step Ill-Select
Appropriate Educational
Methods
0
After formulating the specific educational goals based on the needs
of the paiient and the family, the appr.opriate educational methods
should be selected to meet each goal. The process of selecting educational methods should not be performed by the educational consultant alone, but it should be a cooperative venture among all professional staff members.
Selecting educational methods that are appropriate for the learning
content involves identifying opportunities and situations for patient
education for each of the goals. In order to identify these opportunities.
it is important to be cognizant of each patient's flow pattern through
the facility, the different starr members who will be involved in his care.
his treatment and rehabilitation plan, and the number of other patients
with similar conditions who might be following a related regimen.
With this information, it is possible to list the opportunities for patient
education. Decisions must be made to determine which opportunities
will be used, whic" techniques are best, and whether the methods
will be individual, group, or a combination.
11
91
Generally, the personal or individUal methods should be implemented
by persons working· directly with the patient, such as the physician,
nurse, occupational therapist, recreational therapist, physical therapist, dietitian, social worker, speech therapist, medical technologist,
and others providing service. Group methods can be used by health
specialists from the community or from the facility serving the chronically ill.
At times, an opportunity to provide patient education may occur as
a result of the patient's rehabilitation regimen; for example, a physical
therapist's explanation of the necessity for a certain conditioning procedure represents an application ot a personal method to an opportunity. Other times, however, the procedure becomes more involved,
thus requiring special planning; far example, group instruction programs for diabetic patients.
Criteria for selecting educational methods should include effectiveness, efficiency, adequacy, and appropriateness.
Effectiveness is the extent to which an activity achieves the goal. An
educational method is considered highly effective if it attains the goal.
Efficiency is the amount of resources used to attain the goal. Factors
to be considered in efficiency are manpower, time, materials, and
monies. The educational activity which uses the least amount of resources to attain an educational goal is considered to be the most
·
efficient activity.
Adequacy is the degree to which an educational activity can achieve
the goal. An activity by itself can be quite inadequate; however, when
that activity is combined with another activity, a synergistic effect
could occur whic~ would make the combination highly adequate.
Appropriateness is the relevancy of the method toward achieving the
goal with respect to the ecologic environment of the patient. It is quite
possible that an educational method could be effective, but at the
same time be inappropriate because of a hereditary defect or an
environmental problem. For example, using a tape recorder as an
educational device for persons with normal hearing can be a very
effective educational method, but it is quite inappropriate for persons
with impaired hearing. A pamphlet containing the same information
may be more appropriate, especially if the person is an avid reader.
With respect to group methods, frequently there is greater chance for
behavior change when patients with similar illnesses seek solutions to
their problems togl3ther; for example, classes may be conducted for
certain types of patients such as diabetic, orthopedic, ophthalmo-
12
92
logical, and cardiac. Different teaching and learning techniques may
be used such as demonstration, film discussions, and role playing.
With respect to audiovisual techniques. two relatively recent innovations should be considered: closed circuit television and programmed instruction. Other audiovisual techniques and materials
that could be used include posters, pamphfets, exhibits, slides, films,
mass media, and newsletters.
Time and place should be determined by the patient's schedule and,
when possible, his wishes. For example, a stroke patient probably
will be extremely tired after a vigorous physical therapy session and
probably not as receptive to educational approaches at that time. The
place for imparting information also should be considered. If the
environment presents too many distractions, whether visual or audible,
learning is not as likely to occur. Common sense for time and place
can be a fairly safe guide.
To select appropriate educational materials, the staff should possess
certain basic knowledge and skills:
1. A belief in the educational method and a willingness to help
people learn for themselves.
2. An ability to recognize all educational opportunities.
3. A knowledge of educational process and an ability to determine
selectively the types of situations that can be used to achieve
different educational goals.
4. A knowledge of strengths and weaknesses of different educational
methods and an ability to apply selectively the various methods to
the situations.
5. A knowledge of available community resources and the ability
to use these resources effectively.
A supportive and flexible administrative structure which is conducive
to using educational opportunities existing in all aspects of the institution's operation is essential in accomplishing the educational task.
The educational consultant must have the educational .equipment and
other resources needed to carry out his responsibilities effectively.
Educational tools such as films, slides, overhead projectors. tape
recorders, chalkboards, and literature are important. Without such
educational aids the program often cannot be carried out adequately
and effectively. The educational consultant also must have the necessary time to plan and coordinate the educational activities and to
follow through and evaluate their effective.ness.
13
93
The institution cannot divorce itself from its environmental setting and
still maintain high quality educational programs; it should maintain
good rapport with other organizations, agencie~. and the general
public.
Since some smaller facilities may not be able to employ a full-time
educational specialist, several health facilities in a community may
consider employing jointly such a specialist. The educational specialist's or health educator's functions in a hospital or other institutional setting generally are no different from those practiced in other
settings; these include consultation on educational methodology, assistance in in-service education, and developing the educational component of the medical care program.
Step IV-Carry Out the
Educational Program
Although this is set as the foucth of five steps, it does not start immediately after Step Ill and end abruptly before Step V. Rather, it is a
part of a continuum; it begins at the first step and continues through
evaluation, which, of course, is part of the task of carrying out the
educational program.
Step V- Evaluate
Patient and Family
Education
Since improved patient care is the primary goal of the educational
task within each setting, the major focus of evaluation should be related to the progress the patient makes as a result of the educational
program.
14
94
In considering the model as a design for organization, certain commonalities exist for any institution involved In organizing an education
program:
1. Early planning for evaluation through a clear definition of goals
to be evaluated; and
2. Early identification of methodology for evaluation.
Certainly, If the goals cannot be Identified easily, there cannot be an
identification of methodology by which success or failure is measurable. For example, a goal such as "to have patients lead a happier
and more productive life" is laudable, but hardly measurable since
as yet there are no objective means of measuring happiness and
contentment.
If, however, the goal were defined as "to reduce the amount of excess
sodium excreted over dietary allowances," then there Is a measurable
goal which is specific and attainable. Likewise, a goal may be defined
which Is behaviorally oriented, such as "to prepare the patient to
accept the responsibility for his self-medication program." This requires not only behavioral change among patients but also among
staff who have to prepare the patient and the ·administration which
must provide a climate for education.
Evaluation of goals must be constant and continuous lest the professional person develop routine prescription procedures for behavior
change, forgetting that he is dealing with an Individual patient.
Families need to be considered in any evaluation scheme in order to
assure that goals once reached are maintained by the patient, the
family, or both.
There should be constant evaluation about the informational content
patients and family are provided. Generally, the goals progress from
the simple to the more complex. Questions which should be continually asked include, "Are they being given too much information or too
little?" "Are they being confused by a ·plethora of facts?" ''Can they
perform as adequately with less information and, .if so, how much
less?" Evaluation must be done periodically so that necessary modifications in the plan can be made.
In evaluation it is also necessary to ask if the methods chosen to
provide Information are those which will insure adequate performance
using staff and patient time to the best advantage. Consider such
questions as "Is a one-to-one approach used because historically
this has been the method, or can group-work do the job more ade15
95
quately?" "Are new techniques called for, such as programmed instruction, video tape, and single-concept films, and, if so, are they
being used?"
One team member-preferably the educational specialist-should
have prime responsibility for the coordination and re-evaluation of the
goals. Priorities of goals set tor the patient and family in the educational pr~scription should be determined by the team at regularly
scheduled periods. Acceptance and understanding of the goals by
the group enable each member of the team to pursue his own subgoals wilh less danger of fragmentation. Involving the team throughout
in the planning process provides them with a broad and deep learning
experience and will also influence their behavior and attitude.
In those insta.nces where there is no educator on the staff, a physician,
social worker, or nurse with training in educational methods may act
as coordinator.
In summary, evaluation should be considered an integral aspect of
planning. It should be based upon educational goals; it should be
constant; it should be done by all persons involved in the program;
and it should be completed in an atmosphere of administrative permissiveness and cooperation.
16
96
THE MODEL
Steps in Planning:
Step I. Identify Educational Needs
of Patient and Family
A. Determine knowledge, attitudes, and skills patient and his family
need from a medical point of view to:
• understand patient's illness; .
* understand patient's care:
• cooperate and participate in treatment program.
HOW:
Working from the medical diagnosis, treatmei'lt plan, and prognosis,
specify knowledge and skills patient and family must ha·1e to benefit
from the care for which each member of. health care team is respon·
sible.
•
WHO:
The relevant staff.
WHEN:
Obtain basic information as soon as possible with periodic review
and also at time of discharge.
B. Determine to what extent patient and his family already possess
knowledge, attitudes, and skills, e.g.,
• What does patient already know about his illness, his treatment
(prescriptions, meaning of instruction, etc.), his prognosis, his role
In the treatment program, and resources available to him?
17
97
• What misconceptions does he have that may affect his response· to
care?
• What attitudes does he have that may affect his response to care,
either favorably or unfavorably?
• What needed skills do patients and family already have which ·wilt
help in treatment?
• What skills or present behavior may need to be relearned?
HOW:
By reviewing the patient's medical history.
By checking with medical personnel who previously cared for patient.
By interviewing patient and his family (both direct and indirect).
By listening attentively.
By observation of patient and family.
C. Determine educational goals from point of view of patient and his
family.
• What would the patient and his family like to know or do?·
HOW:
Interview patient and family.
Step II. Set Educational Goals for Patient
and his Family
A. Review possible educational QOals for patient and family as identified by health care team and by patient and family in terms of:
• deficiencies in knowledge and skills of patient's family;
• willingness and interest;
• ability to carry out assignment.
18
98
•
·HOW:
Share and review information collected in Step 1:
• by written summary;
• by case conference.
WHO:
All members of health care team.
WHEN:
As soon as possible after initial medical evaluation and decisions ·
about medical treatment, and periodically thereafter.
8 . Assess difficulty in reaching each goal.
• What ktnds of learning are involved for patient and his family? How
long might this learning take? What personnel, materials, and other
resources would be needed, and are these available?
HOW:
Analysis of each goal in terms of what must be learned, factors aiding
or impeding learning, possible methods to reach goals, and cost of
these methods.
WHO:
Education Specialist.
C. Determine priority of goals.
ii
In what sequence would goals be met to facilitate treatment?
• Which goals are essential (for both short-range and long-range
treatment program)?
HOW:
Staff conference.
19
99
WHO:
All members of health care team.
D. Decide on short-range and long-range educational goals.
HOW:
Staff conference.
WHO:
All members of health care team with patient and family.
61ep Ill. 8ehJct npproprlalo Educational Mothod1
to MeetEoch Educational Oonl Uol for ·
Pallenl and Fumlly
A. ldontify opportunities and situations for patient and family education for each of the goals.
HOW:
Suggestions could be made by, staff working with the Educational
Consultant.
WHO:
All members of health care team.
WHEN:
As soon as possible after educational goals are set.
B. Review possible methods for reaching each educational goal.
HOW:
Individual instruction; group instruction; ·use of visual aids; self-instructional material.
C. Determine specifically what is to be taught, by whom, where, when,
and how.
20
100
HOW:
Through the use of the educational prescription.
WHO:
Each member of the health care team should be involved in decisions.
Step IV. Carry out the Educational Program
(This step is part of a continuum; it starts with Step I and continues
through Step V.)
Step
v. Evaluate Patient and Family Education
A. In terms of the patient's progress at stated intervals, to what extent
were educational methods chosen which were:
• effective?
• appropriate?
• efficient?
HOW:
Feedback from individuals and agencies involved in care.
WHO:
Public Health Nurse, family, physician,· therapy personnel, and local
providers of health care should be involved in follow-up after discharge.
B. To what extent were educational needs from the medical point of
view adequately identified?
• What did we think was·a need which really wasn't necessary?
• What patient and family educational needs did we overlook or
slight?
21
101
HOW:
Set through evaluation.
Patients and their families as well as staff should be involved In evaluation.
C. To what extent were patient and family educational needs as
identified by the patient correctly recognized by staff?
HOW:
Informal evaluation.
WHO:
Staff.
0. To what extent were patient and family knowledge, attitudes, and
skills adequately assessed at beginning of planning?
HOW:
Through evaluation.
•
WHO:
Patients and their families should also be involved in evaluation.
E. To what extent were the educational goals which were set re_iilistlc,
adequate, and time~y?
HOW:
Feedback from all the parties and agencies involved In care, espe.cially those working with the patient after discharge from rehabilitation
extended care facility.
WHO:
All providers of health care should be involved in follow-up after d,ischarge.
F. Were goals given the best priority?
22
102
HOW:
Same as E.
WHO:
Same as E.
G. To what extent were educational methods chosen w!lich were
appropriate, effective, and efficient?
HOW:
Same as E.
WHO:
Same as E.
23
U.S. GOVfi,.....(NT PliiNTING OJFI<:l
103
1975 0-591-175
APPENDIX B
THE QUESTIONNAIRE
104
QUESTIONNAIRE
DIRECTIONS:
Please place a circle around the appropriate
rating which best reflects your professional
opinion.
Read each statement below and decide how you
feel about it. There are no right or wrong
answers; your immediate reaction to the
statement is desired.
1.
A hospital administrator must be a policy-maker, an
innovator and initiator of medical care programs to
meet health needs.
Strongly
Agree
5
2.
5
4
3
Disagree
2
Strongly
Disagree
1
Agree
Uncertain
4
3
Disagree
2
Strongly
Disagree
1
Rising health care costs concern nearly all Americans.
Therefore, hospitals can help in reducing costs by
establishing programs aimed at educating patients and
the community about their health.
Strongly
Agree
5
4.
Uncertain
The administrator involved in program planning and
program development must have a broad social view of
the total community he wishes to serve.
Strongly
Agree
3.
Agree
Agree
Uncertain
4
3
Disagree
2
Strongly
Disagree
1
The American people must ultimately assume individual
responsibility for their own health.
Strongly
Agree
5
Agree
Uncertain
4
3
Disagree
2
105
Strongly
Disagree
1
5.
An educated consumer can help reduce health care costs
by not overutilizing health resources.
Strongly
Agree
5
6.
5
5
3
2
Strongly
Disagree
1
Agree
Uncertain
4
3
Disagree
2
Strongly
Disagree
1
Agree
Uncertain
4
3
Disagree
2
Strongly
Disagree
1
The implementation of management techniques such as
PERT, for use throughout the hospital, can be sources
for cost containment.
Strongly
Agree
5
9.
4
Disagree
The new and time tested management techniques used
in the different industries of the American economy
should be used in the hospitals.
Strongly
Agree
8.
Uncertain
Allowing consumers to actively participate with a
hospital in the decision making process for health
education programs strengthens community commitment
for health prevention.
Strongly
Agree
7.
Agree
Agree
Uncertain
4
3
Disagree
2
Strongly
Disagree
1
Using the PERT technique, administrators can expect
improvements in efficiency and productivity from
hospital personnel.
Strongly
Agree
5
Agree
Uncertain
4
3
Disagree
2
106
Strongly
Disagree
1
10. Information and feedback on hospital operations is
necessary for administrative decision making.
Strongly
Agree
5
Agree
Uncertain
4
3
Disagree
2
107
Strongly
Disagree
1
DIRECTIONS:
1.
The following questions require a
"yes," "No" or brief fill in answers.
Does your hospital have an inpatient education
program?
Yes._ _
2a.
In planning stages.___
Does your hospital have a committee that sets
general policy for all inpatient education programs
conducted by the hospital?
Yes.___
b.
No_ _
No.___
In planning
stages~-
If yes, please specify the name of the committee.
(Check~ answer only.)
Executive Committee
Patient Education committee
Other {please specify)
--
c.
If yes, please indicate which of the following have
• membership on this committee.
(Check as many as
applicable.)
Physician._ _
RN_ _
Trustee~­
Administrator· - -
3a.
Has a specific hospital department been designated
to coordinate inpatient activities?
Yes._ _
b.
Educator._::-Social Worker
Dietitian
-Other {please specify)
No._ _
In planning stages___
If yes, which department has this responsibility?
{Check~ answer only.)
Administration
Education
--Nursing,__.,.Public Relations
Social Service;...._.._
Personnel' - - Other {please specify)
·---
108
4a.
Is there a person from this department designated
to coordinate inpatient education in your hospital?
Yes
No
--
b.
If yes, what is his/her title?
c.
Does this person devote all of his/her time to the
coordination of inpatient education in your
hospital?
Yes
5.
No_ _
Do you use outside consultants to help plan your
inpatient education program?
Yes
No_ _
109
DIRECTIONS:
In your own words please express your
ideas, reactions or thoughts to the
next three questions. You may write
as much or as little as you want.
1.
What should be the role of the hospital administrator
in implementing and supporting a patient education
program?
2.
Would the proposed model of administrative procedures,
starting on page 18 of the chapter, allow for the
APHA's patient education program to be implemented
in a hospital setting?
3.
What are your opinions towards PERT, and its
potential widespread implementation on all types
of projects and programs within your hospital?
110
APPENDIX C
LETTER AND POST CARD SENT
TO ADMINISTRATORS
111
August
1979
Dear Administrator,
As a candidate for a master of science degree in
hospital administration, at California State University,
Northridge, I am conducting a study for my thesis on the
role of the hospital administrator in patient education.
Specifically, I have designed administrative procedures,
aided by a management technique, that I believe would
allow the administrator to be the initiator and organizer
of a patient education program for his institution.
The results of my research from the literature
indicate that hospital based patient education programs
have been successful in helping patients cope with a
chronic illness; is a distinct factor in cost containment;
and is an important source for behavior modification in
the patient.
If you agree to participate in this study, I would
like to send you the chapter of my thesis which
demonstrates the management technique, and the designed
model for implementing a patient education program. A
brief questionnaire also would be included. Since you
represent a select group of hospital administrators your
cooperation, participation and expertise are essential.
The study population is thirty, so it is extremely
important that I obtain every response in order to have
sufficient data for the analyses. Please be assured that
your response will be treated in strictest confidence.
Enclosed you will find a stamped, self-addressed post
card indicating whether or not you will be able to
participate in this study. On the post card a special
code with a letter and number will serve to identify your
institution. Thank you in advance for your cooperation
and assistance.
Respectfully yours,
Robert w. Morgenstern
457 No. Orange Drive
Los Angeles, California 90036
Telephone:
112
(213) 931-5596
POSTCARD
_ _ YES.
I am willing to
participate in your
study.
_ _ NO.
I am unable to
participate in your
study.
Your code number above identifies your
institution.
113
APPENDIX D
FOLLOW-UP LETTER
114
October 8, 1979
Dear Administrator:
About six weeks ago you were kind enough to agree to
participate in my study on the role of the hospital
administrator in patient education. Unfortunately, I
have not received your survey questionnaire, and because
this study has a small number of administrators participating, the statistical analyses cannot be completed.
I am taking this opportunity to send you another copy of
my questionnaire. In the event that you have returned
the first one which may have been lost in the mail,
please accept my apology for burdening you once again with
this matter. The code number on the questionnaire identifies your institution.
·
I wish to thank you for your patience and your cooperation
with this study.
Respectfully yours,
Robert Morgenstern
457 North Orange Drive
Los Angeles, CA 90036
115