Transcript Hospitals: Origins, Organization and Trends

Hospitals:
Origins, Organization, and Trends
Yaseen Hayajneh, RN, MPH, PhD
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Hospitals in 18th. Century
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Pesthouses, almshouses, infirmaries.
 Hospitals were for:
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Contagious sailors and shipboard victims
The poor, mentally ill, and homeless
Patients with family and means received
health care at home.
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Hospitals in 19th. Century
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Unsanitary conditions
 Overcrowdedness
 Little medical care
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Religious groups improved situations.
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Revolutionizing Hospital by 1900s
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Factors
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Nursing training and care
Effective anesthesia
Antiseptics
Sterilization
By 1900s, hospitals changed from supplying
food & refuge to poor and contagious to
providing skilled care to everyone.
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Hospitals Expansion
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Hospital insurance
 Medical advances
 Medical specialization
 Federal support:
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Hill-Burton Act
Medicare & Medicaid
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Federal Laws
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Hill-Burton Act of 1946
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Shortage of hospitals
Provided matching grants to communities to build
hospitals
Involved in construction of nearly 40% of beds (
50’s and 60’s)
Especially evident in rural areas
Medicare & Medicaid of 1965
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Coverage for 65+
Coverage for low income
Provided incentive for more expansion
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Escalating Costs of Hospital Care
PPS
Managed
Care
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Escalating Costs of Hospital Care
PPS
Managed
Care
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From Retrospective to Prospective (PPS)
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Retrospective Payment System:
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A payment system in which the amount a hospital
receives for treating a patient is based on the
expenditures incurred.
Unlimited
Discouraged Frugality and efficiency
“No cost was too great when it came to health care”
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From Retrospective to Prospective
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Prospective Payment System (PPS, 1983):
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A payment system in which the amount a hospital
receives for treating a patient is fixed in advance by
Medicare or an insurer. If the treatment costs more
than the payment, the hospital absorbs the loss; if
the treatment costs less, hospitals keep the
difference.
Fixed amount.
Encourages frugality and efficiency
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Managed Care
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A term that applies to the integration of health
care delivery and financing. Managed care
plans, such as an HMO, manage or control
what is spent on health care by closely
monitoring how providers treat patients.
 Limit referrals to costly specialists and require
preauthorization for hospital care and services
to keep costs down.
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Hospitals Downsizing
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Revenue shrinkage:
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Rising costs
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Prospective payment System (1983)
Bargaining power of Managed Care
Uncompensated Care
Technology, drugs, services
Inflation
Advanced Technology
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Reduced need for admission, Outpatient services
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From Inpatient to … Trend
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From Inpatient to Outpatient:
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Advanced technologies
Avoidance of high cost & fixed payment (PPS)
Increased hospital efficiency
From Inpatient to Home care:
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Formation of organized delivery systems
Advanced technologies
Aging of America
Anticipated federal cuts
retrospective payment for Home care
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Hospital Changes in the 1990s
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Closures (2000 since 1980)
Mergers
Conversion to other health care facility types
Decreased length of stay (one third)
Formation of organized delivery systems
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AKA: Integrated delivery networks
Networks of providers and payers to provide the
continuum of care.
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Functions of Modern Hospitals
Health system support
Employment
Referrals
Professional leadership
Base for outreach activities
Management of primary care
Health professionals
Other health care workers
Suppliers
Teaching
Research
Vocational
Undergraduate
Postgraduate
Continuing education
Basic research
Clinical research
Health services research
Educational research
Transport services
Patient care
Inpatient, outpatient and day patient
Emergency and elective
Rehabilitation
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Classification of Hospitals
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Public Access
Ownership
Length of stay
Number of beds
Accreditation
Teaching
Vertical Integration
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Classification by Public Access
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Degree of public access
 Community vs. Non-community
 Community
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Non-federal, short term, general
Non-community
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Federal, long-term, infirmaries, chronic disease
hospitals and specialty hospitals
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Ownership or Control
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Government, non federal;
 Nongovernmental, not for profit
 Investor-owned, for profit
 Government, federal
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Length of Stay
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Short-term vs. long-term
 Short term < 30 days average
 Long term > 30 days average
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Accreditation
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Accredited vs. nonaccredited
 Accredited
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Joint commission (JCAHO)
Osteopathic Association
Nonaccredited
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Teaching
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Teaching vs. Nonteaching
 Teaching physicians
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Full: offer at minimum 4 residencies
Partial: offer 2-3 of the basic residencies
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Vertical Integration
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Primary, secondary, or tertiary
 Primary: offer services on outpatient basis
 Secondary: more sophisticated, inpatient
 Tertiary: highly specialized services requiring
highly technical resources.
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Hospital Organization &
Structure
Make sure to examine the examples of hospital organizational
charts linked to from the module.
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Organization
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A systematic arrangement of two or more
people or entities who fulfill formal roles &
share a common purpose.
 Purpose, people, and developed structure.
 Examples:
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University, shop, clinic… Small – very large.
Bureaucracy: a type of organization where
individual positions & clusters of positions are
grouped in a hierarchy or pyramid
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Hospital as a bureaucracy
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Division of labor: specialization per task.
 System of policies: formalized guidelines for
actions.
 Span of control: optimal # of staff a single
supervisor can manage.
 Unity of command: each employee reports to
one and only one boss.
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Hospital as a bureaucracy
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Delegation: assigning decision-making power
to lower levels in organizations
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Delegator always responsible
Line vs. staff
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Line authority: direct authority
Staff authority: advisory authority
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Hospital Departments and Services
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Medical Division
Nursing Division
Allied health services
Diagnostic services
Rehabilitation Services
Nutritional Services
Administrative Departments
Hotel Services
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Medical Division
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Provision of medical services.
 Ensuring quality of services.
 Training & teaching of medical students &
Trainees.
 Conducting research.
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Medical Division
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Headed by Chief of Staff
Consists of physicians, mostly.
Recommends appointment of physicians.
Medical Division consists of departments
Each dept. headed by department head.
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Medical Departments*
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Anesthesia
Clinical Pharmacology
Emergency Medicine
Family Medicine
Laboratory Medicine
Limb Center
Medicine
Neurosciences
Obstetrics & Gynecology
Ophthalmology
Orthopedic Surgery
Otolaryngology
* Georgetown University Hospital
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Pathology
Pediatrics
Physical Medicine and
Rehabilitation
Psychiatry
Radiation Medicine
Radiology and Interventional
Radiology
Rehabilitation Medicine
Surgery
Urology
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Nursing Division
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Provision of Nursing Care.
 Coordination of all aspects of patient care.
 Single largest component.
 Divided according to:
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Type of pt. care, skills, and resources needed.
Emergency, Endoscopy, Obstetrics, Home Care,
Inpatient Rehabilitation, Intensive Care Unit (ICU),
Medical/Surgical, Pediatrics, Oncology, Outpatient
Services (OPS), Post Anesthesia, Surgery
Services, Transitional Care Unit, Urology
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Allied Health Professionals
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Provide services that support physicians &
Nurses.
 > 200 occupations
Anesthesiologist Assistants
Athletic Trainers
Audiology
Lab Technologist
Music Therapists
Occupational Therapy
Perfusionists
Physical Therapy
Radiological Technologists
Speech-Language Pathology
Dental Technology
Medical Technology
Radiologic Technology
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Diagnostic Services
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Perform tests to diagnose illness and Monitor
progress.
Laboratory
Hematology
Biochemistry
Microbiology
Pathology
Histopathology
Cytology
Radiology
Mammography
CT Scan
Ultrasound
Cardiac Catheterization Lab
Endoscopy
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Rehabilitation Services
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Specialized care to assist patients in achieving
optimal functioning.
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Physical Therapy
Occupational Therapy
Speech Language Therapy
Sports Medicine
Psychologists
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Other Services
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Pharmacy: Acquisition & dispensing of
medications to inpatients & outpatients.
 Social Services: Assist patients to achieve
optimal social and domestic environment for
recovery.
 Nutritional Services: Food and dietetic
services, and Nutritional education.
 Hotel services: Maintenance, Security,
Laundry, Telephone
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Hospital Complexity
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Number of employees.
Number of different occupations.
Shared power between CEO, Board of
Directors and Physicians.
Amount of data collected and transmitted.
Possible number of pathways of data
transmission.
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Types of Medical Errors
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Overuse: subjecting patients to tests,
procedures, & medications that cannot help
them, or are known to cause harm.
 Prescribing antibiotics for treatment of viral conditions.
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Underuse: failure to offer patients diagnostic
tests & treatments that are proven to improve
their outcomes.
 Unnecessary surgeries, medications, or diagnostics.
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Misuse: poorly executed tests and procedures
 Mix-ups, errors, and flaws - whether or not the test or
procedure was appropriate in the first place
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Leading Causes of Death (US 1997)
Source: Centers for Disease Control and Prevention, National Center for Health Statistics.
National Vital Statistics System and unpublished data. 1997.
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Leading Causes of Death (US 1900)
Source: Centers for Disease Control and Prevention, National Center for Health Statistics.
National Vital Statistics System and unpublished data. 1997.
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Causes of Medical Errors
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Majority of errors do not result from individual
recklessness, but from flaws in health system
organization (or lack of organization)
 Failures of information management are
common:
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illegible writing in medical records
lack of integration of clinical information systems
inaccessibility of records
lack of automated allergy and drug interaction
checking
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Do Electronic Medical Records
Make a Difference?
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YES.
 EMRs:
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Shorten inpatient Length of Stay
Decrease adverse drug interactions
Improve the consistency and content of medical
records
Improve continuity of care & follow-up
Reduce practice variation
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