The Role of the Hospital in a Changing Environment Bulletin of the WHO, 2000,786

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The Role of the Hospital in a Changing
EnvironmentBulletin of the WHO, 2000,78(6)

• Martin McKee Judith Healy
• LSHTM, London
• By Keerti Bhusan Pradhan
• keerti_at_aravind.org

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Summary

• Hospitals a challenge in Healthcare Reform
• Evolving role of hospitals
• Changing Healthcare Needs
• Emerging Technologies
• Size and Distribution of hospitals

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Essence of the Article

• Hospitals must continue to evolve in response to
  factors
• Changing healthcare needs
• Emerging Technologies

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Key Reform Strategies

• Behavioral Interventions-Quality Assurance
  Programs
• Changing Organisational Culture
• Use of Financial Incentives

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Reform Challenges

• Hospital Buildings, Designs
• Hospital functions
• Barriers to change

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Crucial Questions

• I. Why are hospitals created?
• Has the growth in knowledge technology
• invalidated the 19th century foundations?
• What do we mean by Hospital?
• II. If hospitals are to be integral parts of
  healthcare system?
• What should they look like?
• How should they be distributed?
• What should they look like inside?
• How can hospitals be designed in ways that
  enhance their performance (outcome economic)

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Questions

• Why do some hospitals seen to work well where as
  others not?
• How can hospital performance be optimized?
• Hospitals are not black boxes but are complex
  adaptive human systems

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Why Hospitals?

• Changing pattern of diseases
• Changing life style
• Changing environment
• Technology advancement
• Clinical specialties
• Financially-50 of overall healthcare expenditure
  is for hospitals
• Organizationally-Dominate the health care system
• Symbolically-viewed as main manifestation of
  healthcare system

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Challenges

• Scarce resources in terms of skilled staff and
  equipment hence needs concentrated facilities.
  Not dispersed across small facilities
• To provide care rather than cure. Care requires
  people rather than equipment, generalists rather
  than specialists. Access is more important

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What Should a Hospital Look Like?

• Configuration of hospital services-Centralized or
  Dispersed
• Centralized-High volume-Better outcome and
  Economies of scale
• Dispersing Hospital-Improves access and reduces
  inequalities

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Greater Volume-Better Health Outcome

• Practice make perfect
• Selective referral
• Greater specialization than the size
• Process of care is important than just the
  outcome
• Physician volume or Hospital Volume
• (Collective expertise of the entire team)

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Economies of Scale Scope

• For Concentration
• Large hospitals (200-400 beds)
• Different specialties under one roof
• Links between different specialties
• Optimal use of expensive equipment
• Against Concentration
• Reduce access to care
• Access is more important in primary care, out
  patient services and screening programmes

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Improving Clinical Performance

• Incentives for optimizing clinical performance
• -Quality Assurance Models
• -Clinical Audit
• -Clinical Governance (Managerial and Clinical
  responsibility)
• Clinical behavior is resistant to change
• No change following conferences/short educational
  events
• Behavioral change-Range of interventions

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Organizational Environment

• Relationship between organizational culture and
  quality of care
• Better relationship b/w Doctors and Nurses
• Organisational and Professional job satisfaction
• Patient centered culture
• Effective collaboration
• Open approach to problem solving

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Changing payment mechanisms

• The ideal mechanism would be one that offered
  incentives for producing effective, efficient and
  equitable treatment, with no perverse incentives
  and with minimal transaction costs
• A perfect system is not achievable, since there
  are inevitable tradeoffs
• Financial incentives, while good at pushing
  behavior in a certain direction, are less good at
  putting limits upon financial motivation

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Looking ahead

• What the hospital of the future should look like?
• Will we still need the hospital or can its
  functions be performed elsewhere?
• Factors-Changing burden of disease
• Emergence of previously unknown disease
• Size of the workforce in healthcare
• Development in Technology

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Hospital of the Future

• The hospital of the future must respond to all
  these challenges. It must balance economies of
  scope with optimal access, drawing on advances in
  technology.
• It may need fewer beds, but it will need more
  operating theatres and recovery areas
• The hospital need to be flexible, because the
  diseases it treats and the ways in which it
  treats them will be very different from those of
  today

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THANK YOU