Re-inventing the hospital
During recent years hospitals have had to face constantly new challenges. So far, the solutions offered in Germany are not sufficient. On the contrary — rather than solving problems, they tend to create new ones. A change of paradigm in the organisation of hospitals is imminent and hospitals have to change radically, argues economist Holger Richter MA, Managing Director of Bremerhaven Hospital
Medical services
About 90% of hospital income is generated in the 35 weekly working hours of regular day shifts. However, due to new work time regulations fewer and fewer physicians are available for these productive shifts and much of the work time is spent in the 133 working hours of the 'unproductive' night shifts.
Albeit, medical services efficiency is a crucial factor in a hospital’s survival strategy. This means, in view of the shortage of physicians and of funds to pay additional medical staff, there is only one solution: capacities should 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 must be reduced.
Many administrative or low-skill tasks, e.g. taking blood samples or document management, can be performed by clerical staff and medical assistants, freeing doctors to concentrate on their core tasks: diagnosis and therapy.
However, hospitals will not be prepared to finance increasing personnel costs without proper assurance that the work time paid is used sensibly. The management is thus asked to control workflow effectively and efficiently.
A well-structured work environment can help to increase efficiency. However, a prerequisite, namely standardisation of medical processes, has not yet been realised. Organisation still happens by rule of thumb, despite the fact that the introduction of DRGs 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 be standardised to realise significant efficiency gains. The crucial, in essence cultural, precondition to bring about this change is the willingness and discipline to follow these standards.
Medical career
The traditional career path – specialised medical training that leads either to a high-status private practice or to a hospital ‘tenure track’, i.e. to positions as assistant medical director and eventually medical director – seems a decreasing 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, hospitals should offer attractive, adequately paid jobs below the medical director level, which come with status, long-term perspectives and 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 specialised field. While this would increase personnel costs it also – and more importantly – would increase hospital performance.
Nursing services
Since the early 90s, nursing staff is increasingly skilled and trained. While many nurses acquire additional qualifications and specialisations, the majority of their tasks are housekeeping, self organisation and messenger services, which account for 75% of their work time – yet are tasks for which most nurses are overqualified. To improve cost efficiency, simple tasks can be allocated to other functions. There are already successful pilot projects underway in which nurses’ assistants, housekeeping, service and hotel staff are employed.
On the other hand, highly qualified nurses could 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 doctors are prepared to hand over case and process management tasks to nurses.
Key issue: logistics
Hospital traffic is immense: Hospital hallways buzz with staff, permanently on the move. They accompany patients to examinations, hand carry reports, files and images because the electronic patient record (EPR) is still not a reality. Long distances between diagnostic, treatment, surgery and care facilities, scattered all over a hospital complex, force staff to spend more time in transit than in the workplace where they belong. These superfluous logistical processes generate superfluous costs of around 20%. Today, PACS, digital ordering, EPRs and electronic scheduling, as well as electronic stock and purchase management, are all possible and should be minimum standard. The core work areas of a hospital must be restructured. With short routes 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 optimise the economics of medical treatment. Over the last few years, the ‘profit accounting centre’ at the Institute for the Hospital Remuneration System (Institut für Entgeltkalkulation im Krankenhaus – InEK) has gained wide acceptance as a 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 far too often falls by the wayside – a fact 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-centred emphatic care can work wonders. If we conclude that, in the current system, empathy has become almost 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 for one goal: to make empathy possible again.
01.07.2008
