Re-inventing the hospital

Medical services

In hospitals approx. 90 percent of the income is generated in the 35 weekly working hours of the regular day shifts. Due to new working time regulations, however, fewer and fewer physicians are available for these productive shifts and much of the working time is spent in the 133 working hours of the “unproductive” night shifts.

Albeit, efficiency of the medical services is a crucial factor in the survival strategy of a hospital. That means in view of the shortage of physicians and of the funds to pay additional medical staff, there is only one solution: capacities have to be redefined. Medical capacities need to be concentrated in those shifts in which most medical services are delivered. In turn the level of healthcare services provided in late, night and weekend shifts has to be reduced.

Many administrative or low-skill tasks such as taking blood samples or document management can be performed by clerical staff and medical assistants which will free trained physicians to concentrate on their core tasks: diagnosis and therapy.

The hospitals, however, will not be prepared to finance increasing personnel costs without proper assurance that the working time paid is used in a sensible way. Management is thus asked to control workflows effectively and efficiently.

A well-structured work environment can help increase efficiency. A prerequisite, though, namely standardisation of medical processes, has not been realized yet. Organisation still happens by rule of thumb despite the fact that the introduction of DRG and the concomitant financing problems should have created sufficient pressure to reconsider internal structures.

Technical approaches to identify, measure and calculate major and minor processes in hospitals are very promising. Frequently only a few major processes need to be standardised in order to realize significant efficiency gains. The crucial, in essence cultural, precondition to bring about this change is the willingness and the discipline to follow these standards.

 

Medical career

The traditional career path – specialised medical training which leads either to a high-status private practice or to the hospital “tenure track”, that is to positions as assistant medical director and eventually medical director – seems to be less and less an option for young physicians who are well aware of the financial and the reform pressure burdening the healthcare system. A new generation of physicians is therefore prepared to consider career alternatives. Consequently, the hospitals should offer attractive, adequately paid jobs below the medical director level which come with status, long-term perspectives and which allow a decent work/family balance. One option is to create a new medical middle-management level for physicians, so-called functional assistant medical directors who are specialised and manage their area of specialisation. While this would increase personnel costs it also - and more importantly -would increase the performance of the hospitals.

 

Nursing services

Since the early 1990s, nursing staff is increasingly skilled and trained. While many nurses acquire additional qualifications and specialisations the majority of the tasks they perform are housekeeping tasks, self organisation and messenger services. Most nurses are overqualified for these tasks, which account for 75 percent of a nurse’s work time. In order to improve cost efficiency, simple tasks can be allocated to other functions. There are already successful pilot projects under way in which nurses’ assistants, housekeeping, service and hotel staff are employed.

Highly qualified nursing staff on the other hand can assume more responsibility and perform both medical and case management tasks. It remains to be seen, though, whether nursing staff are willing to assume medical assistant tasks and whether physicians are prepared to hand over case and process management tasks to nursing staff.

Key issue: logistics

Hospital traffic is immense: Hospital hallways are buzzing with staff who seem to be permanently on the move. They accompany patients to examinations, they hand carry reports, files and images because the electronic patient file has still not become reality. Long distances between diagnostic, treatment, surgery and care facilities that are scattered all over the hospital complex force staff to spend more time in transit than at their work place – where they belong. These superfluous logistical processes generate superfluous costs in the vicinity of 20 percent. Today, PACS, digital ordering, electronic patient files and electronic scheduling as well as electronic stock and purchase management are possible and should be minimum standard. The core work areas of a hospital have to be restructured. With short ways and short waiting times staff will perform better and patients will be more satisfied.

Data management to support decisions

Hospital management has many possibilities to optimize the economics of medical treatment. Over the last few years, the InEK’s (Institut für Entgeltkalkulatiom im Krankenhaus – Institute for the Hospital Remuneration System) so-called profit center accounting has gained wide acceptance as decision-making support tool. It provides benchmark-oriented profit and loss accounting as well as continuous DRG calculation which generates actual cost data for each case. Excess costs as well as shortfalls are identified and their causes can be analysed.

All required data are automatically culled from the overall hospital information system and from functional sub-systems. For hospitals a professional software solution is as indispensable as the above-mentioned standardisation of processes.

 

 

Empathy

A major success factor of any hospital is the level of empathy patients receive. But today, in the face of organisational and structural weaknesses, empathy fat too often falls by the wayside - a fact which is deplored by patients and staff alike. In modern society the avoidance of suffering plays an enormous role and in addition to any pain therapy human-centered, emphatic care can work wonders. If we arrive at the conclusion that in the current system empathy has become nearly impossible we need to ask who can serve as a model and how can we improve the situation. The organisational and structural changes suggested above are not merely technocratic, on the contrary, they all aim at one goal: to make empathy possible again.