A.

History
A health care system is the totality of services offered by all health disciplines
(Berman, Snyder, Kozier, & Erb, 2008). It includes people, organizations, facilities and resources
to meet the needs of the population.
A health care organization must be concerned with doing the right things through efficacy
and appropriateness and doing the right things well

through availability, timeliness,

effectiveness, continuity, safety, efficiency and respect and caring (De Laune & Ladner, 2011)
Throughout the centuries, a lot of changes have occurred in the field of health care. The
primitive system of health care years ago has evolved to todays advanced and improved health
care.
During the fifth and sixth centuries, Christianitys early years, churches and monasteries
works not only include providing of food, clothing shelter and spiritual support to those in need
but also, serving the sick. In the middle ages, several religious orders of men provided nursing
care to both western and eastern health institutions. Also at this time, institutions were
established to house patients with communicable disease like leprosy (Wall,n.d.).
In the eighteenth century, hospitals increased in size and focused more on the medical
aspect than the religious side. In America, isolation hospitals and almshouses were built for the
sick and for the poor as well. Benjamin Franklin and Dr. Thomas Bond spearheaded the
establishment of Pennsylvania Hospital in 1751 (Wall, n.d.).
In the nineteenth century, Napoleon built big hospitals with more than a thousand beds in
France to accommodate his wounded troops from the wars (Wall, n.d.). In 1859, Florence
Nightingale, the founder of modern nursing created the Nightingale Training School for Nurses
at St. Thomas Hospital in London. Non-profit hospitals supported by religious groups, public

hospitals and proprietary hospitals were also established during these times. In United States,
hospitals became more modern and expensive during 1865-1925.In 1887, Mrs. Bedford
Fenwick, a well-known leader in England campaigned for nurse registration. After a year, she
founded the British Nurses Association which later became the Royal British Nurses
Association. In 1893, professionals and artists attended the Worlds Fair and Columbian
Exposition in America. The gathering of nurses, mostly directors of nursing paved the way to the
eventual formation of American Society of Superintendents of Training Schools for Nurses. The
standard of nursing education was their focus. In 1907, Canadian nurses also created the
Canadian Society of Superintendents of Training Schools. The American organization was later
renamed to the National League for Nursing Education in 1912 and eventually to National
League for Nursing in 1952 (Ellis & Hartley, 2008).
In 1910s, American hospital became more scientific, emphasized the value of antiseptics
and cleanliness and used pain medications (Public Broadcasting Service, n.d.). During the Great
Depression in 1930s-1940s, patients turned to public health institutions instead of privatelyowned hospitals. In April 7, 1948, the World Health Organization was formed by the United
Nations. Medicare and Medicaid were created in 1965 to provide financial support to the aged
and people in need especially those with low income (Berman et al., 2008). In 1970s,
community hospitals offered complex and advanced services such as open-heart surgery,
radioisotope procedure and in-house psychiatric facilities.Hospital costs escalated due to some
factors such as high Medicare expenses, rapid inflation of the economy, increase of hospital
expenditures and profits and advancement in technology, medication and treatments (Public
Broadcasting Service, n.d.). In 1980s profit and non-profit health institutions started forming
bigger hospital systems. A system was a corporate entity that owned or operated more than one

hospital (Wall, n.d.). Cost control was the focus of hospitals in the 1990s. Medicare and
Medicaid continued to be influential and insurance companies became more active in managing
hospital costs.
In the Philippines, Fray Juan Clemente, a Franciscan friar established a dispensary in
Manila in 1577. It later became the San Juan de Dios Hospital in 1659 (Department of Health,
2011).Aside from San Juan de Dios Hospital, the San Lazaro Hospital is also one of the old
hospitals in the country. On September 2, 1922, AnastaciaGiron-Tupas founded the Filipino
Nurses Association which became the Philippine Nurses Association in 1966. The Department of
Health was separated from the Department of Public Health and Welfare as an individual entity
in 1941. From the 1950s onwards, there was a steady improvement in patient care, medical
education, and public health comparable to other developing countries(Romualdez, et al., 2011).
In 1969, the Philippine Medical Care Act approved hospitalization, medical and surgical expense
benefits for Filipinos. Health care services were classified into primary, secondary and tertiary
levels in 1970. Private sector health services, free-standing hospitals, physician-run individual
clinics, and midwifery clinics, have mainly followed the North American models of independent
institutions which were based on fee-for-service payments. From 1990s onwards, health projects
such as Nutrition Project, Traditional Medicine and Doctors to the Barrio were pushed further
(Department of Health, 2011). In 1995, the PhilHealth was established as the national health
insurance corporation (Romualdez, et al., 2011).
B. Structure and Organization of Health Care
1. Primary, Secondary and Tertiary
Innovations in biomedical science have almost eradicated scourges such as polio and
measles and have allowed such marvels as organ transplantation, knifeless gamma ray surgery
for brain tumor, and intensive care technology that saves the lives of children with asthma

complicated by pneumonia. In cases such as the failure to prevent severe asthma flare-up is not
related to financial barriers, but rather reflects organizational problems, particularly in the
delivery of primary care and preventive services (Bodenheimer & Grumbach, 2009).
The organizational task facing all health care systems is one of assuring that the right
patient receives the right service at the right time and in the right place (Rodwin, 1984). An
additional criterion could be . . . and by the right caregiver (Bodenheimer & Grumbach, 2009).
Who is responsible for planning and ensuring that every child receives the right service at the
right time? Can an urgent care center or an in-store clinic at Watsons designed for episodic
needs be held accountable for providing comprehensive care to all patients passing through its
doors? Should parents be expected to make appointments for routine visits at medical offices and
clinics, or should public health nurses travel to homes and day-care centers to provide preventive
services out in the community? What is the proper balance between intensive care units that
provide life-saving services to critically ill patients and primary care services geared toward less
dramatic medical and preventive needs?
Primary Health Care
The first level of contact between individuals and families with the health system refers
to the Primary Health Care (Kareem, 1996). According to the Alma Atta Declaration of 1978,
Primary health care is essential health care based on practical, scientifically sound and socially
acceptable methods and technology made universally accessible to individuals and families in
the community through their full participation and at a cost that the community and country can
afford to maintain at every stage of the development in the spirit of self-reliance and selfdetermination. It included care for mother and child which included family planning,
immunization, prevention of locally endemic diseases, treatment of common diseases or injuries,

provision of essential facilities, health education, provision of food and nutrition and adequate
supply of safe drinking water (Department of Health, 2011).
In the Philippines, the goal of Primary Health Care is Health for All Filipinos by the
year 2000 and Health in the Hands of the People by the year 2020. There are two levels of
Primary Health Care workers, the Barangay Health Workers, who are trained community health
workers r health auxiliary volunteers or traditional birth attendants or healers, and the
Intermediate Level Health Workers, includes the Public Health Nurse, Rural Sanitary Inspector
and midwives (Primary Health Care (PHC)).
Elements of Primary Health Care
Education for Health
It is one of the potent methodologies for information dissemination. This helps promote the
partnership of both the family members and health workers in the promotion of health as well as
prevention of illness (Primary Health Care (PHC)).
Locally Endemic Disease Control
This focuses on the prevention of occurrence of endemic disease to prevent morbidity rate
(Primary Health Care (PHC)).
Expanded Program on Immunization
This program controls the occurrence of preventable illnesses especially of children below 6
years old. Immunizations on poliomyelitis, measles, tetanus, diphtheria and other preventable
disease are given by the government and ongoing programs of the DOH for free.

Maternal and Child Health and Family Planning

As the name implies, this program focuses on the most delicate members of the community, the
mother and child. The goal of Family Planning includes spacing of children and responsible
parenthood (Primary Health Care (PHC)).
Environmental Sanitation and Promotion of Safe Water Supply
Environmental Sanitation is the study of all factors in the mans environment, which exercise or
may exercise deleterious effect on his well-being and survival. As a basic need for life, water is
necessary for the maintenance of healthy lifestyle. This program is necessary for basic promotion
of health (Primary Health Care (PHC)).
Nutrition and Promotion of Adequate Food Supply
There are many food resources found in the communities but because of faulty preparation and
the lack of knowledge regarding proper food planning, malnutrition is one of the problems that
we have in the country (Primary Health Care (PHC)).
Treatment of Communicable Diseases and Common Illness
Most communicable diseases are preventable. The Government focuses on the prevention,
control and treatment of these illnesses (Primary Health Care (PHC)).
Supply of Essential Drugs
This focuses on the information campaign on the utilization and acquisition of drugs. In response
to this campaign, the GENERIC ACT of the Philippines is enacted (Primary Health Care (PHC)).
Secondary Health Care
If a person has been referred to a specialist by the primary care provider, then he/she has
been referred to secondary care. Secondary care simply means being taken care of by someone
who has more specific expertise in whatever problem a person is having (Torrey, 2011).

Secondary Health Care includes smaller, non-departmentalized hospitals including district

hospitals and rural hospitals. Services offered to patients with symptomatic stages of disease,
which require moderately specialized knowledge and technical resources for adequate treatment
(Primary Health Care (PHC)). Secondary care is where most of us end up when we have a
medical condition to deal with that can't be handled by primary care. Sometimes, problems with
specialty care develop because we have been referred to the wrong kind of specialist (Torrey,
2011).
Tertiary Health Care
Tertiary health care lies at the apex of the organizational pyramid which involves the
management of rare and complex disorders (Bodenheimer & Grumbach, 2009). Specialized
consultative care is provided usually on referral from primary and secondary medical care
(Kareem, 1996). Tertiary healthcare services are specialised and are a highly technical level of
healthcare, which involves diagnosis and treatment of disease and disability. These services
involve the specialised intensive care unit, highly trained doctors and health workers, whose
main role is to offer healthcare (Bodenheimer & Grumbach, 2009).
2. Profit & Non-Profit
The health care system is composed of different health care providers, consumers and
settings. A health care organization can either be a profit or non-profit organization. No single
agency or group controls the entire health care system(De Laune & Ladner, 2011).

Profit Health Care Organization

Throughout the history of the health care industry, a lot of non-profit organizations have
been created, providing services to those in need of medical attention. However in the last 20

years, several for-profit organizations such as hospitals and dialysis centers have also been
established (Andre & Vasquez, 2010).
Profit organizations are said to provide quality service and benefits at affordable costs because of
their efficiency, cost-cutting and innovations. This cost-cutting trend was attributed to managed
care, with the percentage of hospitals participating in managed care programs almost doubling
between 1993 and 1994 (Sackman, n.d.). Most non-profit organizations work independently. On
the other hand, for-profit organizations are usually connected to each other, allowing for
economies in financing and management, centralized services and shared equipment, thereby
leading to lower costs (Andre & Vasquez, 2010). They also have easy access to capital which is
necessary to replace outdated materials and machine with new and improved ones, unlike nonprofit health care organizations. For-profit institutions pay taxes and by doing so, they believe
that they can contribute to societys welfare through these remittances.
However, there are also disapprovals thrown to profit organizations. They are said to
serve only those who are rich and avoid receiving uninsured patients. In addition, they could
promote highly-lucrative drugs, tests and treatments instead of the cheaper and traditional ones.
Non-Profit Health Care Organization
Non-profit organizations are important part of the public health sector. These are
voluntary agencies that are funded through different ways such as individual contributions,
corporate philanthropy and membership dues(De Laune & Ladner, 2011).As a non-profit health
care organization, they aim to provide care and services without regard of the patients capacity
to pay (Layne, n.d.). These organizations are responsible to the communities and populations
they serve. The earnings of non-profit health care organizations are reinvested to benefit the
community (Alliance for Advancing Nonprofit Health Care, n.d.).Theyrun health care

institutions which are usually operated by religious organizations or other community

groups(Government of Saskatchewen, 2012).
Consideration of justice is the concern of non-profit organization. All persons have a
right to live their lives with dignity (Andre & Vasquez, 2010). They believe that every member
should be given the right to health care access, whether they are rich or poor, particularly in
wealthy countries such as America.
Contrary to for-profit organizations which have ample source of capital, non-profit
organizationshave difficulty attracting funds because they depend on donations and support.
Some people dont consider going to them because of the stigma that these are public
institutions and that some of their facilities are aging and outdated (Andre & Vasquez, 2010).
Non-profit hospitals are either operated as a charitable or educational institution or both.
Some charitable hospitals include faith-based hospitals and community hospitals. There are also
other non-religious affiliations that offer help. Educational hospitals are also prevalent. They are
usually university-affiliated and focus on student education and research. These hospitals usually
use new technology and experimental techniques. There are also research institutions which
conduct research but are not university-affiliated. Examples of these research institutions are the
Mayo Clinic, Scripps Institute and City of Hope in Duarte, California. Apart from hospitals, there
are also other non-profit health care agencies (Feigenbaum, 2013).
Most public health programs are considered non-profit organizations. Recipients of these
programs usually pay a little amount or none at all. Free clinics, immunization clinics, hospice
care for the indigent and AIDS prevention program are some of the services they provide
(Feigenbaum, 2013).

Examples of not-for-profit organizations in U.S. are the American Nurses Association and
the American Medical Association. There are also organizations which provide educational
resources to health care providers and general public. These include U.S. agencies like the
American Cancer Society and the American Heart Association(De Laune & Ladner, 2011).
Aside from the aforementioned groups, there are more public health service
organizations. The Health Resources and Services Administration (HRSA) provide the public
with health-related information and spearhead programs about health care to the homeless, organ
transplant, HIV-infected and AIDS patients, and impart knowledge about rural health care and
employee occupation health. The Food and Drug Administration (FDA) protects the public from
the use of unsafe drugs, food and cosmetics. The Center for Disease Control and Prevention
(CDC) assists in preventing the transmission of communicable diseases. The National Institutes
of Health (NIH) conducts research and education about specific diseases. Lastly, the Alcohol,
Drug Abuse and Mental Health Administration (ADAMHA) tackles on information about
substance abuse and other mental health issues. These institutions are some of the organizations
supported by the U.S. Public Health Service(De Laune & Ladner, 2011).
There has been a great issue between non-profit and for-profit organizations, on whether
which type benefits the society more or which agency delivers the better health care service than
the other. In the end, these organizations are all under the health care system. They ought to
provide care to those in need to elevate the standard of health in any society. Truly, as previously
mentioned, neither of them controls the entire health care system.

C. CHANGING DEMOGRAPHICS AND HEALTH CARE

The variation of different demographics has constantly affected health care worldwide.
Increased number of elderly, geographical location and economics are just some of the factors
involved.
Aging Population
By 2020, it is estimated that people over the age of 65 years old in America will be more
than 53 million 10 million more than the current population (65 years old and above). This
statistics is alarming considering that the elderly require close attention. They are usually
affected by long-term illnesses and require special housing, treatment services and financial
support. Since only 5% of the elderly are institutionalized, home management and nursing
support services will be essential for these patients. In addition, health care organizations should
not only focus on the elderlys health but consider their worth and productivity as well, through
special programs (Berman, et al., 2008).
If health care consumption patterns and physician productivity remained constant over
time, the aging population would increase the demand for physicians per thousand population
from 2.8 in 2000 to 3.1 in 2020. Demand for full-time-equivalent (FTE) registered nurses per
thousand population would increase from 7 to 7.5 during this same period (Changing
Demographics: Implications forPhysicians, Nurses, and Other Health Workers, 2003).
Uneven Distribution of Services
Urban and rural areas have different health care opportunities. Rural areas generally have
shortage of health care services compare to urban areas with adequate health institutions,
personnel and services. Patients in rural areas often travel long distance in order to access health
care services. Efforts to increase the supply of health professionals in these areas must deal with

economic, cultural and language considerations (Changing Demographics: Implications

forPhysicians, Nurses, and Other Health Workers, 2003).
An increasing number of health care workers provide specialized services. This
specialization can cause fragmentation of services and increased expenses.
Urbanization / Advances in Technology
Due to the modernization, health care delivery has constantly improved. High-end and
sophisticated diagnostic procedures have helped in early detection of diseases. More medicines
have also been produced to treat different diseases and even the more complicated ones. Also, a
lot of surgical procedures, which were non-existent 20 years ago have already been performed.
Due to the modernization of technology, the public are becoming aware of their health situation
through the use of computers and internet. However, because of the escalation of health care
standards, these treatment and procedures entail higher costs for the people.
Economics
Paying for health care services is becoming a great concern. A countrys economic status
affects the delivery of health care. Berman et al. (2008) indicated the major reasons for the
escalation of costs. Health care institutions continue to improve their facilities and equipment in
order to keep up with the pace of modern health. The increase in population, especially the
elderly and uninsured has also caused the increase of costs. Due to improved technology, more
people are becoming aware causing them to seek for health assistance. There is also an increase
in the number of health care providers. And lastly, medicines are also becoming more costly.

Poverty
The health problems of homeless and poor are usually exacerbated due to their inability
to avail of health care services. Physical, mental, social, and emotional factors create health care
challenges for them (Berman et al., 2008).
Womens Health
Womens movement has caused health care organizations to give attention to womens
needs. Childbirth services have been improved. Womens health issues such as osteoporosis and
heart disease are addressed. There is also an increased emphasis on the psychosocial aspects of
womens health.
Family Fragmentation
Single-parent families and alternative family structures have been prevalent. Women are
usually the head of these single parent families. They often are working individuals and need
support in providing care for their children, especially when they are sick.
Cultural and Ethnic Diversity
Health care organizations give emphasis on patients differences in culture. To address
this problem, institutions employ personnel who can communicate in English.
D. THE CULTURE OF HEALTHCARE ORGANIZATIONS
Culture is the characteristics of a particular group of people, defined by everything from
language, religion, cuisine, social habits, music and arts (Zimmermann, 2012). It is how and
why you do what you do (Wiseman & Kaprielian, 2005). According to Wiseman and Kaprielian
(2005), culture is made up of the overarching themes within an organization usually made up of
stories and unwritten rules governing behavior which might be clearly stated or merely implied,
intentional or unintentional.

Culture is not necessarily uniform within a single organization. For example, in a

hospital, each healthcare worker may have a different culture. These differences may either
benefit or impede the patient care. The latter is more likely, as cultural differences frequently
result in communication differences (Wiseman & Kaprielian, 2005).
In the healthcare environment, the culture of an organization has many competing
variables. The conflicting needs of patients, families, providers, institutions, regulators and
others create many discrepancies and mixed messages (Wiseman & Kaprielian, 2005). Many
have said that a culture of blame has been pervasive in healthcare. Because medicine was often
viewed as the work of a sole physician (or other professional) working with an individual patient,
when something did not go well the automatic reaction was to try to determine who was at fault
and, often, to discipline them. This shame and blame approach leads to hiding rather than
reporting of errors, and thus is the antithesis of a culture of safety. Recent efforts have tried to
change thisto encourage people to report problems rather than hide them, so they can be
addressed. Forward-thinking healthcare organizations remember that their primary reason for
existence is to take care of patients, and they want to keep them as safe and healthy as possible.
There are formal and informal cultures in an organization. Difference between the formal
operational style stimulated by the management and the style demonstrated and felt by staff
members may be evident. This can result in an incompetent organization. Therefore, the culture
of an organization definitely affects quality of care. A positive culture produces trust, information
sharing, collaboration and risk taking. On the other hand, a negative culture promotes
divisiveness, resistance and a desire to maintain the status quo leading to employees lacking
creativity and self-direction (De Laune &Laudner, 2011).

Here is an example of two different cultures in a health care organization:

Tim recognized the unique way the teams at Hospital A worked when during a fairly
serious procedure a nurse spoke up and asked for a procedural stop. The physician had given a
verbal order for an antibiotic in conjunction with the procedure. She questioned this because of a
recollection that the patient had several drug allergies. The team held the procedure until the
record was reviewed, and it was confirmed that the patient was indeed allergic to the medication
that was ordered. The physician gladly changed the order, an alternative medication was
administered, and the procedure was then performed. Afterwards, the doctor actually thanked the
nurse for her willingness to ask the question.
Tim realized this was truly a different world than he had lived in at Hospital B. He
recalled nurses avoiding raising questions about doctors orders because of the consequences. He
specifically remembered one physician dressing down a nurse right outside the exam room,
fully within earshot of the patient and a number of other workers. There had been some
management intervention and a workshop on teamwork as a result, but it was common
knowledge that the nurse received a written warning while the doctor got only a mild verbal
reprimand.
In the above example, Hospital A exemplified a positive organizational culture as
evidenced by open communication between the members of the health care team. The nurse was
not afraid to speak up while the physician was open to corrections. In the end, they were able to
identify and correct the error and promote the welfare of the patient. On the other hand, nurses in
Hospital B were afraid of raising questions because of fear of getting reprimanded by the
physician.