Since the passage of the Patient Protection and Affordable Care Act (PPACA), I have had the opportunity to engage a wide variety of colleagues, policymakers, and noted health care thinkers about the effects of health care reform on hospitals. With the hindsight of over 30 years managing hospital operations, I have developed the strong belief that if hospitals are to improve significantly the systemic delivery of care we must commit to making bigger changes than may seem reasonable. Moreover, hospital administrators entering the field will do well to consider changes of this scale as the “new norm” that will likely govern the industry for the next several decades.
Proposed reforms, like Medical Homes, Accountable Care Organizations and bundled payments, have consumed much of the focus since passage of PPACA, yet they will not be enough to achieve the national goal of high quality, low cost care. Many progressive organizations have been successfully utilizing variations of this payment methodology and these delivery systems for extended periods of time, but there is little evidence that national adoption of these delivery systems alone will produce the results the country needs. To have a substantial impact on slowing the growth of care delivery costs we must make a giant leap forward in everything from design of facilities to the processes that govern care delivery to how we utilize information technology.
With more than 5,000 hospitals operating in the country, the thought of altering the fundamental operating design of hospitals may seem to be unreasonable. However, if we are to design a health system for the 21st century then let’s begin from the ground up. The industries that produce the best quality products most efficiently today do not use production facilities designed and built 30-50 years ago. They have recognized the need to streamline facilities so that products move through the operational cycle more quickly; sub processes efficiently contribute to the overall system aim; and information technology delivers a snapshot of any component of the business on demand and in real-time.
Can our most modern hospitals do that? Overwhelmingly the answer is no. Those who say that we are diagnosing and treating people, not creating widgets, miss the essential truth that if we decrease the waste and inefficiency in hospitals, we can free doctors and clinicians from unnecessary tasks and give them more time to spend with patients. By embodying proven efficiency practices already established in other commercial sectors, within the clinical processes currently employed in hospitals, we can establish a foundation for total hospital efficiency that will significantly benefit patients and lowers costs.
For existing hospitals, reducing the logistical challenges that limit patient flow and create waste will reduce average lengths of stay, increase net revenues, increase capacity (making patient beds available more quickly) and establish a foundation for improved quality. As in every other industry that has overhauled the design of new facilities, providers will experience increases in efficiency that become further bolstered by increases in quality.
Building on my assertion that we must go beyond what seems reasonable to achieve major change in hospital based care delivery it is my belief that the HITECH Act’s focus on electronic health record (EHR) implementation is too limited. While digitizing health records, test results, and computerizing order entry will increase the availability and transfer of health information; it will do little to increase the efficiency of the overall care delivery operation. Decision support protocols may help identify the most appropriate care regimen, but to maximize the potential of EHRs, the underlying systems that govern care delivery must be optimized and supported through technology.
Human driven systems tend to degrade over time and efforts to eliminate work-around or inefficient processes in health care will be unsuccessful unless supported by technology that ensures process efficiencies are maintained. Advances in logistics software have the ability to choreograph all patient movements, order execution, and patient handoffs across entire hospitals so that total hospital efficiency is achieved. Additionally, these information systems provide administrators with a real time, system wide view of a hospital’s operations. By viewing patient flow, staffing needs, and process and cycle time data, leadership can make determinations on the most efficient resource allocation.
Adopting electronic health systems in a chaotic environment will not improve care; instead, it will create unnecessary stress and confusion among already overburdened caregivers. By first orchestrating all clinical and non-clinical patient movements in a manner that streamlines patient flow, logistics, and departmental handoffs from admission to discharge, hospitals will be able to achieve immediate, measurable and sustainable gains in system-wide productivity and patient care. EHRs will support these advances but will not produce the system performance needed.1
To meet these challenges of health reform, hospital executives must be prepared to move beyond the dictates of PPACA and HITECH and reconsider the foundations of hospital based care. From design to operational methodologies to the use of information technology, we must be prepared to go beyond what the hospital industry has always considered reasonable and appropriate. We must embrace and adapt the success of other industries if we are to create a new norm that delivers high quality, low cost care.
1 “Hospital Computing and the Costs and Quality of Care: A National Study”, Himmelstein – Wright – Woolhandler, American Journal of Medicine, 2009