The above links will take you to the Center for the Health Professions site.

Centering on...Leading Hospitals

Is it unfair to consider every admission to the hospital a failure of the American health care system? Much of what passes for health policy these days - from access to an insurance card, to the performance of the emergency medical transport system, to the number of medical sub-specialists that are trained - seems to be focused on insuring that patients have access to the hospital as we know it now. For most of the public, of course, this seems like just what needs to be done. But this perspective is not informed by knowing that most of the patient safety and quality shortfalls and the majority of the rising costs of health care come from the hospital. Yes, it is the locus of many of the miracles of modern medicine. Just as certainly, however, it is the embodiment of what has gone awry with health care in the US.

There are, of course, instances when a hospital - with its vast array of technology and specialized care - is necessary. But at some fundamental level, don't most trips to the hospital point to some failure of other parts of the health care system or other social services? Because we can't or don't fund preventative health interventions we end up shipping problems off to the hospital. This is not the hospital's failing, of course, but as we consider how hospitals respond to the changing environment that was discussed in this column last month, it will be essential to fully understand what is needed from these institutions and how they might be best structured and organized. Otherwise, we will fall prey to the trap of supporting and propping up institutions that no longer provide the services we need, rather than refashioning health care to meet our needs. Instead of continuing to pay for the system that we know, we should provide incentives for creating the system that we need.

The hospital clearly plays a critical role in the health care system, and consumes the lion's share of the resources that are spent on health care. If we are truthful, it is also where most of the errors occur around quality of care and patient safety. Changing it is a complex and daunting undertaking. This should not deter us from pursuing change, but it does require that we focus our efforts on the most fundamental challenges facing hospitals. This month, I identify and discuss the three most fundamental challenges to our hospitals.

Reform the work - Usually you get the vision correct and then align your resources and strategy to meet the reformed vision. But the problems confronting the hospitals are so significant, it is important that we begin the change process with the resources we now have available. I have been a part of a recent effort to identify and catalogue innovative, new models for hospital care in the development of a unique Web site, innovativecaremodels.com, that was funded by the Robert Wood Johnson Foundation. Some of the models we identified were found in acute care hospitals, some in transitional settings, and some in settings that delivered comprehensive preventative, social and behavioral models of care. What is important about this study is not that we found the "one best model" but that we found examples of how communities of professionals - in concert with patients, families and customers - redesigned the nature of the in-patient experience. Although their models differed, the various processes that they went through to imagine, design and then create their models shared many of the same elements. First, there was a patient or customer defined or driven goal or outcome which became the guiding principle for the change. I realize that health care is always about the patient, but over the years I have found that we sometimes forget to check with patients to see if what they really want is being addressed in accordance with their values. Second, professional prerogatives and hegemony took a back seat to the patient driven goal. This does not mean that professionalism was suppressed or that medicine or nursing values were put aside. It did mean that these professional interests and skills were carefully aligned among interdisciplinary teams working towards shared outcomes. Third, these outcomes were measured in a much more focused way than we typically apply to the assessment of our work in health care. The reform efforts were clear about what they wanted to change, which made it easier to identify the variables - the three-legged stool of quality, satisfaction and cost - that needed to be measured to mark success. Finally, these efforts unfolded over a number of years. What we found in this study was that the most successful care delivery innovations were less about adopting a new technology or learning a new trick, than they were about creating a more patient-responsive environment that involved the entire hospital staff in new ways of thinking about their individual and shared roles. This type of work is around cultural change, not just improvement, and it takes time to come to fruition. Cultural change work should be an active part of the agenda for any hospital planning to be successful in the next decade.

Reform the vision - Each of the reforms we identified on [insert hyperlink] innovativecaremodels.com was informed with a vision, a point that goes beyond the very good work in which each of the hospitals were engaged as they created their new approaches to care. This broader perspective raises the question as to whether we need a new idea about what the hospital is or should be. Today's hospitals are, in general, complex places where technology and highly specialized professionals are gathered together to focus intensively on providing high acuity care. Medical errors are borne, in part, out of the complexity of today's hospitals. This is one of the reasons hospital costs are so high. As the roles of specialized technologies and professions have grown, they have worked to limit the focus of the hospital. Anyone who has ever been discharged following even a simple procedure has experienced the quickly waning interest of most hospitals in care that goes on afterwards or prevention that precedes an admission. Certainly, this is driven by the fact that hospitals are not paid for such work, but imagine how differently positioned the hospital would be if it took a much more active and engaged interest in this broader continuum of health and health care. Consider the intense interests, desires, and questions the general public has about its health - a set of interests that is likely to be enhanced by an admission to the hospital. These interests present a development opportunity to which most hospitals are completely blind. Just the data management opportunities associated with an average visit to the hospital would create almost boundless opportunities for other types of organizations. But there are many other visions of the hospital that can be imagined: community anchor, health center focused on optimizing health and hospital avoidance, economic development resource, provider of health professional education, or valued consultant on creating healthy workers. Any or all of these could move from the role of ancillary service or activity to core mission and dramatically reposition the hospital in the transitions that lie ahead.

Reform leadership - To achieve either of these reforms, the particular innovations that are profiled in the new care delivery model study or other new visions of what a hospital could be will require leadership. Successful change efforts will need to be tied to the traditional role and function of the hospital and the services it has provided in the community, but they will also need to be firmly fixed on the challenges ahead and the new pathways to move institutions toward the new goal. Such changes, the ones that require new directions while improving on existing commitments, are the most difficult. These efforts will be most successful when they are done in partnership with new stakeholders, whether from the business community, the broader public, public officials or others who see the need and value for new types of hospitals. Over the next few years a small number of organizations will begin this process. Some will be the most competitive institutions with established reputations and others will be relatively unknown. There will be a modest vision of a truly new type of hospital which will be articulated by an incumbent leader. It will be shared and will grow well beyond the original idea. Others will see that this approach allows old challenges to finally be met and new activities to be embraced, and they will readily embark in the new directions. Someone once observed that health care in the US is "over managed and under led." My hope is that there are still hospital leaders out there who are willing to take a swing at leading, even when merely managing will still suffice to wrap up a successful career.

For more information about innovative care delivery models, visit: innovativecaremodels.com.

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