Hospitals: Origins, Organization, and Trends

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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 (
  50s and 60s)
• 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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Escalating Costs of Hospital Care
PPS
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
Health system support Referrals Professional
leadership Base for outreach activities Management
of primary care
Employment Health professionals Other health care
workers Suppliers Transport services
Teaching Vocational Undergraduate Postgraduate Con
tinuing education
Research Basic research Clinical research Health
services research Educational research
Patient care Inpatient, outpatient and day
patient Emergency and elective Rehabilitation
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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 lt 30 days average
• Long term gt 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.
• gt 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

• Perform tests to diagnose illness and Monitor
  progress.

Radiology Mammography CT Scan Ultrasound Cardiac
Catheterization Lab Endoscopy
Laboratory Hematology Biochemistry Microbiology P
athology Histopathology Cytology
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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