Problem: Declining life expectancy during the mid-1990s indicated worsening health outcomes in the Russian Federation; risky health behaviours were highly prevalent in the population; service orientation was largely reactive and the availability of health promotion and disease prevention was limited; a restricted scope of practice for nurses left physicians overburdened.
Solution highlights: Polyclinic 15 led an initiative to expand health promotion and disease prevention services by advancing nursing roles. Nurses now independently care for lower-risk patients, perform screenings and deliver health education; expanding nurses’ scope of practice helped to overcome physicians’ capacity barriers. Physicians now report having more time for high-risk patients; continuous training, backed by supportive legislation and incentives, helped to institutionalize new practices; international partnerships supported the transfer of knowledge and advancement of nursing; health education helped empower patients to self-manage their conditions and adopt lifestyle changes.
Description of practice
In the 1990s, health care in the Russian Federation was highly specialized and reactive in orientation. Health promotion and disease prevention services were lacking and prevalent risky health behaviours, such as tobacco use or alcohol consumption, were not adequately addressed by the health system. Physicians in polyclinics were overburdened and had little time to dedicate to proactive care delivery; this situation was exacerbated by a hierarchical professional model which limited nurses’ scope of practice.
Polyclinic 15 – responsible for providing care to 73 000 residents in Samara – led an initiative to expand health promotion and disease prevention services by advancing nursing roles. Under the initiative, nurses at Polyclinic 15 participated in training courses at local institutions to enable them to expand their scope of practice; complementary on-the-job trainings for nurses were also provided by physicians at Polyclinic 15. To further support changes in nursing roles, several infrastructural improvements were also carried out at Polyclinic 15, including the introduction of electronic medical records and a new scheduling system. As a result of the initiative, nurses now play a greater role in care delivery and split their time between independently receiving patients and assisting physicians. Examples of services now performed by nurses include home care visits, cancer screenings and blood glucose testing. Additionally, all patients at Polyclinic 15 now receive comprehensive health screenings and risk-assessment questionnaires and, those with identified health risks (such as high blood pressure or tobacco use), are referred to health education classes taught by nurses. These screenings have contributed to Polyclinic 15 observing earlier detection of health problems. Administrators at Polyclinic 15 routinely collect and monitor health data to identify emerging needs and areas for improvement. A composite score (reflecting both individual and group performance) determines part of health providers’ salaries to help incentivize teamwork and drive improvements in efficiency and quality; administrators alter indices to reflect emerging priorities. Increasing nurses’ understanding of performance indices and continuing to support advanced nursing are ongoing priorities for the administration of Polyclinic 15.
Implementation of practice
What stage is the practice currently in?
Who was/is responsible for the implementation of the practice?
Strong leadership by the administration of Polyclinic 15 carried the initiative forward. Providers across departments at Polyclinic 15, including both nurses and physicians, provided input on the initiative and worked together to implement changes. Development of new guidelines and training programmes for nurses was supported by partners including the Association of Nurses, Samara Medical University and the Centre for Professional Qualification Education. Additional resources and technical support came through an international partnership with the American International Health Alliance. Later, active promotion of the initiative succeeded in gaining funding and support from the Samara Ministry of Health. Today, providers at Polyclinic 15 work closely together in their adapted roles to care for patients.
Polyclinic 15 has been recognized throughout the Russian Federation as an innovative best-practice model. Improvements in screening rates, health education delivery and access to providers have been observed. For example, health risk assessments delivered by nurses almost tripled from 2267 in 2007 to 6675 in 2012, participation in health education schools increased from approximately 1000 patients in 2006 to 11 000 in 2014, and physicians reported having more time for high-risk patients.
This case was prepared as part of a larger effort by the WHO Regional Office for Europe and published (2016) in the document, "Lessons from transforming health services delivery: Compendium of initiatives in the WHO European Region".
© Copyright World Health Organization (WHO), 2016
The methodology used for the development of this case is slightly different from the templates used on the IntegratedCare4People web platform, in particular in the analysis of enabling factors and barriers to change.
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- Larisa Yuldashevna Pudovinnikuva
- Polyclinic 15, Samara