Healthcare Executives Must Lead Change By David Goff Hospital executives are continually initiating new and innovative ways to effectively respond to intense expense pressures from all payers, and quality pressures from the public (Hallam, 1999). However, most expense reduction initiatives fail to fundamentally change how inpatient clinical care is delivered. As a result, the public, doctors and staff are losing confidence in hospitals while the average cost per inpatient case continues to escalate (Moore, 1999). As healthcare executives set their priorities for the future, reinventing the acute care hospital component of their enterprise must be near the top of their list. Many benefits will be realized by refocusing management effort and financial resources upon measurable improvements in clinical care while eliminating all expenses that do not contribute to clinical excellence. First, it may be the only strategy that allows some hospitals to remain in existence. For all, it will reestablish the vital link between the healthcare organization and the clinical staff, including physicians, as well as the community being served. Healthcare is an incredibly complex business and many forces, real and imaginary, have led to a system that has lost the confidence of the American public. Efforts geared towards improved clinical outcomes, lower costs, and increased patient satisfaction, will be supported by the public and place healthcare executives back in their rightful place of leadership. Better care, lower cost Health system leaders must refocus their attention on their unavoidable role of providing higher quality acute care services at a lower cost. However, they must realize that anything short of a total overhaul of how hospitals operate will result in modest cost savings and decreased quality of care (Lathrop, 1993). Significant improvements in quality and cost efficiency can be achieved if leaders take a “back to the basics” approach to evaluating each of the following three key components of their operation: (1) organization of care, (2) allocation of space, and (3) comprehensive application of computerization. Chief Executives must lead this change process. Their major challenge is to convince the many true decision makers within the healthcare environment ( physicians, nurses, and all other clinical professionals ) that it is in their ultimate best interest to participate in reinventing the American hospital. The chief executive must include the following points in leading the organization towards a successful future: (1) The prospects of getting access to enough additional money to perpetuate the current system are nonexistent. (2) If healthcare professionals do not take the initiative to bring about the types of changes that reduce cost and improve care, governments, the insurance industry and employers will continue to drive change. (3) Ultimately, health care professionals have a moral and social obligation to their communities to operate a efficiently as possible and to provide high quality care for the dollars available. (4) Most healthcare professionals know that significant inefficiencies exist in acute care hospitals and most inefficiencies are people related. Everyone in the organization must be willing to change from what is comfortable for the benefit of the patients. The first step in “getting back to the baics” is to revisit the fundamentals of acute care. Putting it in the most simplistic terms, the inpatient delivery system involves four basic steps: (1) the physician admits a patient; (2) the physician makes a diagnosis and orders a treatment plan; (3) treatments are initiated; and (4) the patient is discharged. Inpatient Delivery System Hospitals provide the necessary staff, space, supplies, and equipment to work with physicians to effectively and efficiently administer clinical services to patients. The primary objective is to improve the patient’s health status or, at a minimum, stabilize the patient to a level that does not require acute care. While inevitable variables are encountered throughout this process requiring adjustments in the treatment plan, the basic process is the same for all patients. Organization of Care To achieve optimal efficiency, executives must lead their clinicians towards acceptance of the following key process enablers: (1) treatment protocols, (2) progress pathways, (3) and charting by exception. The treatment protocol is defined as a general practice description that assigns order to tasks and processes to be performed. It becomes the road map for all caregivers. Treatment protocols facilitate the development of progress pathways or progress maps by nursing which assist in defining ancillary schedules and clinical unit staffing levels, including those of clinical support services. Protocols define and predict, within an acceptable range of certainty, the needs of each patient throughout the hospitalization. Clinical documentation by exception must also become the rule because in the average hospital today, nurses spend almost one-third of their time documenting either professional notes or capturing information for administrative purposes (Lathrop, 1993). The documentation systems in most hospitals have not changed substantially for forty years. Innovative use of computer technology can change that. A key organizational goal must be adoption of the automated patient chart as the official record and source document for all other documentation requirements. As doctors are able to dictate orders, progress notes, etc. and report information immediately through voice recognition systems, the treatment process will accelerate and significant costs will be taken out of the system. For those services that can be provided at the bedside, the organizational structure must be modified to allow overall management of the delivery of those services. This means that hospitals should not be organized strictly along departmental lines because such a structure often leads to inefficient execution of the patient treatment process. Specialization and departmentalization became part of the hospital structure over many years for a variety of reasons, but the maximum efficiency of patient treatment was not one of them. That structure must be re-examined and necessary adjustments made to more efficiently manage the patient through the care process. Financial success should be measured by the total cost of a patient’s stay and not by the internal efficiency of departments. The decentralized configuration concept for patient units being proposed makes the number of beds on a care unit less important than under typical nursing organizational structures. With decentralization, the professional nurse is much more independent and self-sufficient. Direct supervision requirements are less because the professional nurse has supplies, equipment, communications, and the computerized patient chart close at hand. However, overall coordination of the entire process is essential and superior clinical management becomes essential. Physical Structures To support the organization of care model described, executives must re-examine today’s hospital space configuration and basic philosophy that drives each and every space change that is made. In order for caregivers to be with their patients, they must have all the tools necessary to do their jobs close at hand. Therefore, a patient unit design that places supplies, equipment, charting, medications, and communications close to the patient bedside and available to caregivers is essential (Lathrop, 1993). Efficient execution of the patient treatment protocol is enhanced with a design geared towards hands-on caregiver efficiency. Assuming the system satisfies the first objective of assisting the primary caregiver in moving the patient progressively through the treatment process, management’s role is to solve peripheral issues, such as inventory control and supply distribution costs. The use of the automated chart as the source document for other documentation needs is the starting point for those solutions (Skaggs et al, 1998). As the hospital is reconfigured over time, patient rooms become all private and large enough to accommodate contemporary clinical requirements and overnight guests who can assist the patient (McKahan). Private rooms eliminate most of the patient transfers for non-clinical reasons, thus cutting out administrative costs and chances for errors. Older hospitals, where possible, should be retrofitted to provide larger rooms with individual bathrooms in each. With the national trend toward fewer inpatients, older facilities can reconfigure space to reduce the number of inpatient rooms and make remaining rooms bigger to accommodate the new systems of care. Larger patient rooms with decentralized support systems and unit configuration more like traditional intensive care layouts will allow for most patients to be cared for on the unit. The current concept of the universal room applies to the ideal hospital (Stouffer, 1997). According to Jeff Stouffer of HKS Inc., “universal rooms accommodate patients of all acuity levels. The room is designed to be easily reconfigured from a critical care setting, rehabilitation or typical medical surgical room. By not designing bed configuration per specific disease and/or acuity categories, hospitals achieve greater care flexibility. The universal rooms also reduce patient transfers between rooms-providing a greater continuity of care.” Since medications are a significant part of most patient’s treatment protocol, pharmaceutical dispensing machines that also track inventory and automatically charge should be evaluated along with other systems that make the patient’s medication readily available to the caregiver. The deciding factors are not capital cost or restocking times, but the speed with which the patient gets the proper medication after orders are written and the efficiency of the caregiver’s time. A reassessment of the amount and location of space allocated for essential equipment and supplies on the clinical unit is also required. The acuity of patients on typical clinical units today is similar to that of critical care units of yesterday and the design of the unit must reflect that continuing evolution by borrowing design characteristics from intensive care units. Likewise, all the necessary communications systems required to increase the efficiency of the unit must be employed. With today’s technology, systems for telephones, paging, and patient bedside communications, at a minimum, can be integrated. New technology has made it much easier to design an acceptable communications system that supports the decentralization of the caregiver to the patient’s bedside. There must also be intense study of all facility design elements with patient movement and treatment efficiency as the ultimate measures of the ideal approach. The patient unit layout and the actual number of acute care beds along with site constraints will determine if the overall building is vertically or horizontally configured. The use of escalators, instead of elevators, for staff and visitors should be considered because they allow for constant movement of people to and from their destination. Dedicated supply distribution systems such as cartveyors, pneumatic tube systems and robots must also be evaluated (Skaggs et al, 1998). All of these require space changes, organizational adjustments, and, most importantly, a change in managerial mindset as to what is first priority. The hospital manager must recognize that operating costs are recurring while capital costs occur once. The goal is to effectively spend capital dollars to reduce or minimize ongoing operating expenses (ibid). Clinical support space must be designed with patient treatment protocol efficiency as first priority and support department efficiency as a close second. The need for and location of each stand alone department must be questioned as space changes are planned. Those clinical services requiring patient movement, such as MRI and CT, are located as close to the patient units as possible to minimize required patient transportation times (Lathrop, 1993). Focusing upon the efficiency of the patient treatment process may result in the creation of more clinical space on the acute care unit. All units should be fundamentally configured alike for long-term flexibility reasons with minor adjustments for specific clinical patient catagories. Non-clinical support services should be located in non-hospital grade space close to the clinical operation only if that is an operational necessity. Consideration should be given to creating one large open space for functions such as medical records, patient accounting, general accounting, purchasing, etc., with common management and total space flexibility. The concept would visibly and operationally demonstrate the requirement of working together for one common purpose. Otherwise, less expensive, flexible space should be provided for as long as it is economically feasible or necessary to provide the service in house. In fact, many of these services can be contracted out or shared with other providers to reduce unit cost and management’s efforts should be aimed at removing them totally from the space equation (McKahan, 1998). No capital should be invested in a support service that is thought to be destined for dramatic change during the life cycle of new space (Skaggs et al, 1998). Computerization In the arena of computerization of healthcare, the CEO’s most vital role is defining, up front, the fundamental objectives of the enormous financial investment required to reinvent the modern acute care hospital. Technology must improve the delivery of the required patient care services and cut operating costs. CEO’s must study how technology has transformed industries such as telecommunications, retailing, the auto industry, and even farming. Cisco Systems, for example, has no in-house purchasing department (prices are negotiated through and outside firm called Ariba) and places orders over the Internet. An order can be executed in about 10 seconds. Through management tools such as “Executive Dashboard” and “Cisco Worldwide Reporting” and “Critical Accounts”, executives can know instantaneously the status of all corporate activity (Ignatius 1999) With the automated clinical chart as the backbone of innovative use of computer technology, all essential data can be aggregated to effectively and efficiently schedule patients for clinical tests and procedures, and identify the appropriate number and skill mix of clinical staff needed on each patient unit, in clinical ancillary departments, and support departments such as dietary. The computer tracks the supply needs of each patient, clinical unit, and ancillary support department supporting the efficiency of the treatment process and reducing supply inventories. The key to computerization is to avoid automating existing “systems” and instead, to redesign all operational practices with the patient care process. Existing departmental systems that introduce inefficiencies into the flow of the patient through the system will need to be scrapped. All patient financial, supply, and statistical information can be abstracted from the patient chart. The fully automated chart can provide all required data as a by-product of the clinical documentation system. For example, most clinical data currently abstracted from the chart manually should be a provided automatically from the automated chart. By documenting patient treatment information in the computerized chart, the caregiver automatically provides the billing department, medical records department, and others the information needed thus reducing staffing requirements in all those areas. Most importantly, the automated chart makes all that pertinent data available to the physician at any time and location. Since the progress pathway is dependent upon the physician’s orders along the way, the more timely the physician gets information on patient progress, the faster new orders can be given, treatments initiated, and the patient processed through the system. Measure for Success The CEO who follows these three principles in leading their organizations into the future will realize the following outcomes: (1) reduced cost per inpatient admission, (2) increased patient satisfaction, and (3) measurable improvement in clinical outcomes (Croswell, 1999; Solovy, 1998). It will not be easy, but all other alternatives bring about less desirable results. For leaders to demonstrate success in this effort, it is essential that creditable information be collected routinely and made available to at least all managers and physicians, if not all employees, to keep them focused on the goals of the organization. In addition, the public is demanding more information on provider performance in each of these areas, and successful hospitals will have measurement systems in place to effectively respond when the data is released to the general population (Solovy, 1998). References Croswell, C. (March 22, 1999). Better, Not Bigger. Construction Costs Soar on Wings of Patient Demand. Modern Healthcare, page 23. Hallam, K. (May 31, 1999). HHS: No quick fix for hospital woes. Modern Healthcare, page 25. Ignatius, D. (July 11, 1999) Online in the New Economy: The Washington Post , Section B, page 7 Lathrop, J. (1993). Restructuring Healthcare: The Patient Focused Paradigm. San Francisco: Jossey-Bass. McKahan, D. (October 1998). Current Trends and Future Forecast. The Academy Journal, Volume 1. Moore, J. (June 7, 1999). Chasm grows between rich and poor: Top hospital performers get stronger as weaker competitors stumble, new research indicates. Modern Healthcare, page 34. 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