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Hospitals: Origins, Organization, and Trends

Yaseen Hayajneh, RN, MPH, PhD

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Hospitals in 18th. Century

Pesthouses, almshouses, infirmaries. Hospitals were for:

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

Unsanitary conditions Overcrowdedness Little medical care

Religious groups improved situations.

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Revolutionizing Hospital by 1900s

Factors 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

Hospital insurance Medical advances Medical specialization Federal support:

Hill-Burton Act Medicare & Medicaid

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Federal Laws

Hill-Burton Act of 1946 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 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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PPS

Escalating Costs of Hospital Care

Managed Care

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From Retrospective to Prospective (PPS)

Retrospective Payment System: 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

Prospective Payment System (PPS, 1983): 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

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

Revenue shrinkage: Prospective payment System (1983) Bargaining power of Managed Care Uncompensated Care

Rising costs Technology, drugs, services Inflation

Advanced Technology Reduced need for admission, Outpatient services

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From Inpatient to … Trend

From Inpatient to Outpatient: Advanced technologies Avoidance of high cost & fixed payment (PPS) Increased hospital efficiency

From Inpatient to Home care: 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

Closures (2000 since 1980) Mergers Conversion to other health care facility types Decreased length of stay (one third) Formation of organized delivery systems

AKA: Integrated delivery networks Networks of providers and payers to provide the

continuum of care.

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Functions of Modern Hospitals

Patient careInpatient, outpatient and day patientEmergency and electiveRehabilitation

TeachingVocationalUndergraduatePostgraduateContinuing education

ResearchBasic researchClinical researchHealth services researchEducational research

Health system supportReferralsProfessional leadershipBase for outreach activitiesManagement of primary care

EmploymentHealth professionalsOther health care workersSuppliersTransport services

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Classification of Hospitals

Public Access Ownership Length of stay Number of beds Accreditation Teaching Vertical Integration

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Classification by Public Access

Degree of public access Community vs. Non-community Community

Non-federal, short term, general

Non-community Federal, long-term, infirmaries, chronic disease

hospitals and specialty hospitals

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Ownership or Control

Government, non federal; Nongovernmental, not for profit Investor-owned, for profit Government, federal

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Length of Stay

Short-term vs. long-term Short term < 30 days average Long term > 30 days average

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Accreditation

Accredited vs. nonaccredited Accredited

Joint commission (JCAHO) Osteopathic Association

Nonaccredited

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Teaching

Teaching vs. Nonteaching Teaching physicians

Full: offer at minimum 4 residencies Partial: offer 2-3 of the basic residencies

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Vertical Integration

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

A systematic arrangement of two or more people or entities who fulfill formal roles & share a common purpose.

Purpose, people, and developed structure. Examples:

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

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

Delegation: assigning decision-making power to lower levels in organizations Delegator always responsible

Line vs. staff Line authority: direct authority Staff authority: advisory authority

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Hospital Departments and Services

Medical Division Nursing Division Allied health services Diagnostic services Rehabilitation Services Nutritional Services Administrative Departments Hotel Services

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Medical Division

Provision of medical services. Ensuring quality of services. Training & teaching of medical students &

Trainees. Conducting research.

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Medical Division

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*

Anesthesia Clinical Pharmacology Emergency Medicine Family Medicine Laboratory Medicine Limb Center Medicine Neurosciences Obstetrics & Gynecology Ophthalmology Orthopedic Surgery Otolaryngology

Pathology Pediatrics Physical Medicine and

Rehabilitation Psychiatry Radiation Medicine Radiology and Interventional

Radiology Rehabilitation Medicine Surgery Urology

* Georgetown University Hospital

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Nursing Division

Provision of Nursing Care. Coordination of all aspects of patient care. Single largest component. Divided according to:

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

Provide services that support physicians & Nurses.

> 200 occupations

Anesthesiologist AssistantsAthletic TrainersAudiologyLab TechnologistMusic TherapistsOccupational Therapy Perfusionists

Physical TherapyRadiological TechnologistsSpeech-Language PathologyDental TechnologyMedical TechnologyRadiologic Technology

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Diagnostic Services

Perform tests to diagnose illness and Monitor progress.

LaboratoryHematology BiochemistryMicrobiologyPathologyHistopathologyCytology

RadiologyMammographyCT ScanUltrasoundCardiac Catheterization LabEndoscopy

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Rehabilitation Services

Specialized care to assist patients in achieving optimal functioning. Physical Therapy Occupational Therapy Speech Language Therapy Sports Medicine Psychologists

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Other Services

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

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

Overuse: subjecting patients to tests, procedures, & medications that cannot help them, or are known to cause harm. Prescribing antibiotics for treatment of viral conditions.

Underuse: failure to offer patients diagnostic tests & treatments that are proven to improve their outcomes. Unnecessary surgeries, medications, or diagnostics.

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

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: 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?

YES. EMRs:

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