BY: TIM PORTER-O'GRADY, EdD, PhD, and RICK AFABLE, MD, MPH
Dr. Porter-O'Grady is senior partner, Tim Porter-O'Grady Associates International
LLC, Atlanta; Dr. Afable is vice president, medical affairs, Catholic Health
East, Newtown Square, PA.
We are now seeing the beginning of the end of what might be called the "industrial
age of medicine."1 Health care in the 20th century was delivered
almost exclusively in hospitals and long-term care (LTC) facilities. But the
new century has brought with it a focus on new technologies, innovative treatments,
and a new sensitivity to patient preferences, and these have changed how and
where health care is delivered. Today care is often provided in a much less
intensive setting than the hospital or LTC center; sometimes the venue is the
patient's own home.2
Current surgical and procedural trends — including recent developments in minimally
invasive surgery, nanotechnology, and robotics — portend changes as yet unimagined.3
These trends raise certain urgent questions for health care leaders: Are they,
for example, planning now for the demise of the familiar hospital infrastructure?
Are they working for a less institutional, more fluid, highly mobile, and nimble
system than the one they now lead?
Structures of the Past
Almost everyone agrees that today's health care infrastructure is rapidly becoming
obsolete. Here are three examples.
The Changing Role of Nurses About 80 percent of the work done by nurses
is based on the 20th-century belief that health care is best delivered in hospitals
during admissions that require the patient to stay at least several days.4
Yet the average length of patient stays has fallen dramatically in recent years;
for some treatments and procedures, hospital stays have been eliminated altogether.
As a result, much of the work that nurses once performed in hospitals is now
done elsewhere by other people. Although nurses often say they don't have time
to do their work, they fail to realize that much of it could be done in other
settings, often by the patients themselves.
The resulting dissatisfaction has led, on one hand, to nurses' complaints
that they no longer have an opportunity to use all the skills they were taught,
and, on the other, to patients' complaints that they no longer get all the nursing
services they are used to receiving. The so-called nursing shortage is, in an
important sense, additional evidence that the 20th-century hospital system has
become an anachronism.
Both nurses and patients must be reeducated. Patients need to be taught how
to help themselves; nurses need to learn new skills. Neither nurses nor patients
will be satisfied until they change their relationships with each other.
An End to Compartmentalization The new age in health care requires
a much closer alignment of hospitals and physicians, of tangible resources,
on one hand, and cognitive/procedural skills, on the other.5
Unfortunately, the traditional hospital structure impedes this realignment.
The compartmentalization represented by medical staff bylaws, unilateral hospital
governance, and divided clinical and strategic decision making makes it difficult
to establish new relationships. Further complicating factors are laws and regulations
that block a more efficient use of resources. Some critics argue that these
limitations could not merely challenge but cripple the development of U.S. health
care.6
Inadequate and sometimes inappropriate financial laws and regulations especially
constrain the development of necessary relationships between hospital boards
and physicians. But they do not bar them. Boards must put the reform of such
laws and regulations at the top of their advocacy agendas.
For their part, physicians tend to be organized according to medical specialties
and departments. This reinforces compartmentalization, thus hindering the formation
of useful relationships among doctors, boards, and hospital executives. Because
these relationships are absent, there is little discussion of integration or
wholeness in care delivery. As a result, holistic health and wellness programs
are shunted off to practitioners of alternative medicine, nutritional supplements,
exercise, fitness, and related services. It is a testament to the public's hunger
for these products and services that they are among the fastest growing components
of care delivery in the United States. Even so, physicians have not yet begun
to seriously reform medical services in a way that would allow them to address
populations, cultures, and whole persons, not body parts.
Making Medical Staffs Effective Medical staffs were originally created
to help the physicians affiliated with a hospital communicate with each other
and organize their work as effectively as possible. Today, however, the typical
staff is barely organized and, arguably, only minimally effective. Hospitals
still need a medical staff structure to carry out perfunctory processes such
as credentialing and peer review and to satisfy the requirements of accrediting
agencies such as the Joint Commission on Accreditation of Healthcare Organizations.
But the fact is that most patient care provided by physicians now occurs outside
the hospital.
Thus it is naive to think that the medical staff structure is the channel
through which physician relationships are currently conducted. On the contrary,
today's physician-to-physician interaction is usually an informal affair, based
on patient referrals and business transactions. Hospitals and health care systems
that seek to rebuild their relationships with physicians will have to create
new organizational structures. These new physician organizations will be shaped
by patient wishes, market requirements, professional concordance, clinical outcomes,
and regulatory compliance.7 The independent practice association
is a prototype for such organizations, which are self-created and self-governing
bodies likely to be much more patient- and market-focused than the medical staff.
Once the legal constraints on it have been eased, this structure will be the
one that health care systems prefer as a partner.
Such partnerships will require a tight interface between the new physician
organization, on one hand, and the hospital's board structure and processes,
on the other. Peter Drucker has argued that, in what he calls the "Age of Systems,"
relationship building is the primary leadership activity.8 Action
guided by interdependence will determine a sustainable health care framework.
Much of the work of leadership, whether medical or organizational, will lie
in constructing the interfaces needed to bring together key stakeholders so
that they can discern and design the foundations of health care for the foreseeable
future.
Partnership with the New Consumer
Today's consumers seek ever-faster, personalized responses to their demands.
Amazon.com's "Anything, anytime, anyplace" slogan has come to apply to the delivery
of services as well as to products. Although health care is no ordinary set
of products or services, it too must learn to adapt to consumers' heightened
expectations.
Physicians and health care services must now deal with patients who can acquire
health care information and obtain pharmaceuticals, health-related supplements,
supplies, and equipment online, without first consulting a physician. It is
pointless for professionals to lament this shift in power to consumers. Both
physicians and service managers must learn to reconfigure health care services
in partnership with the consumer, thereby guaranteeing that the consumer
needn't seek health care outside that partnership. This new relationship will
make consumers better informed about — and also more accountable for — their own
situations and concerns. Physicians and health care services will have to work
closely in this new arrangement because neither will be able to address consumer
wishes without the other.
A more fluid, flexible, and mobile model of service will be required to sustain
so intensive a relationship with the new consumer. MDExpress.com may serve as
an example. This Internet site has become successful by creating new relationships
with health consumers, in this case their subscribers. Online technology makes
it possible for subscribers to track their interactions with the site and keep
abreast of information relevant to their needs. The site constructs an Internet-based
consumer profile that helps subscribers understand their health status and make
informed choices about it. The site even creates referrals to medical providers,
who, savvy about the process, can interface with the consumer both online and,
when necessary, in person.
Other health care providers may want to use this site as a prototype. Physicians
and hospitals now have no choice but to develop continuous, dynamic relationships
with their "customers," employing the same model of mass customization that
operates in other businesses. In doing so, they must accept certain facts:
- Hospital and physician information infrastructure must interface so that
both can connect with the patient in his or her home.
- Neither the hospital nor the physician "owns" the patient. They must work
together as partners, sharing information, support systems, and communication
media.
- Patients, according to customer relations management theory, are increasingly
unhappy with inconvenience or duplicated efforts that result from a poor interface
between the hospital and physician. They should not, for example, be asked
to fill out personal and health information by both the hospital and
the physician.
- The Internet is not just a communications medium. It is now also an integral
tool for keeping records, gathering information, and even making diagnoses.
Even so, no hospital or physician has as yet used today's technology to bring
provider and patient into a truly new relationship.
New Service and Structural Imperatives
Scripps-Mercy Health System, San Diego, is constructing a comprehensive information
infrastructure for its eight facilities and 1,500 physicians. When completed,
this network will allow both physicians and patients to examine patient care
records, thus ensuring that patients need give information only once in the
service delivery process, wherever the service might occur. It will also relieve
physicians and other health professionals from having to spend time searching
for the information they need.
At the Duke University Children's Hospital in Durham, NC, physicians and hospital
managers have worked together to build a clinical/cost model that establishes
"best practices" for various clinical services.9 An even more important
product of this initiative has been the solid relationships established among
the people and departments involved.
If they are to thrive over the next decade, physicians and hospitals must
build stronger relationships in several key areas.
Board-Physician Leadership New therapies, including genomics, are forcing
top health care leaders to reexamine programs, clinical approaches, service
models, architecture — and their own relationships. Boards and physician leaders
must work together in the strategic planning process, focusing on the development
of service models likely to satisfy market demand.
Besides determining strategy and allocating capital for it, such leaders must
also direct the construction of integrated clinical and financial information
systems that link together hospital and physicians, providing them with performance
data in a "balanced scorecard" format.10
Internet Use As noted, a more intense and sophisticated use of the
Internet will link physician, hospital, and consumer, expediting communication
among them and providing all three with a growing information database.
New Technology Health care leaders will develop a system for more efficiently
researching, assessing, and acquiring new technology. Equally important, this
system will retire technology that has become obsolete.
Clinical Processes and Protocols Health care leaders must develop,
for managers and physicians at the point of care, processes and protocols for
clinical problem solving to ensure a better fit between clinical service and
the clinical characteristics of those served.
Architecture Top health care leaders must reexamine the congruence
between a hospital's current operating infrastructure and the changing format
and content of health care services. They must, for example, deal with the fact
that although most hospitals were built to accommodate patient admissions lasting
several days, today's therapies are increasingly brief and portable.
These last are structural imperatives. Carrying them out will form
a foundation for establishing the performance-based activities needed in a changing
model for clinical services. Unless boards and physician leaders commit themselves
to building a solid structure, the necessary behavioral and relational changes
necessary will not have sufficient support.
A Critical Interface
By now, it should be obvious to most health care leaders that they can no longer
maintain the artificial boundaries between physicians and other components of
the health service system, because such boundaries put the patient at risk.
The compartmentalization of economics, regulation, and service has, in particular,
reached the point where it blocks progress in health care. Three critical areas
need special attention.
Regulation and Finances The primary obstacle facing today's health
care is perhaps its constricting, 20th-century regulatory and financial structure.
Hospital board and physician leaders have no choice but to try to amend that
structure, keeping those parts that ensure good business practices, protect
the best interests of patients, and preclude potentially immoral or unethical
practices. Perhaps the reason that many inadequate and sometimes inane regulations
continue to exist is that stakeholders from both hospital and physician constituencies
still think they can advance their own agenda alone or at the expense of the
other.
Even the most parochial thinker should see that this approach always leads
to failure. Board leaders can accomplish much, especially at local and state
levels, if they will take the helm in creating the relationships and coalitions
needed to get such regulations amended. This action is the only way to accomplish
change. Boards and physician leadership must, for the time being, spend more
of their time working in the public and social arena. The 21st century requires
a new regulatory and financial framework, and hospital and physician leaders
must help create it.
Medical Staffs Hospital boards must also deal with the regulatory and
legal obstacles that block reform of the medical staff system. Only thus can
physicians become part of the decision-making process. On one hand, the board
clearly must address constraint-of-trade and conflict-of-interest issues; protecting
the integrity of both provider and system is vital. On the other hand, laws
and regulations that bar physicians from decision making should be changed.
They are barriers to the creation of new decision-making models that bring stakeholders
together in the development of effective strategy, "best practices," advantageous
market position, more efficient priority setting, firm normative practice standards,
and more clearly delineated quality outcomes.
The longer such reforms are put off, the more the future of health care will
be put at risk. Boards have no option but to make strengthening the structural
relationship between the medical staff and the health care organization a priority.
Technological Implications Design and practice are both inevitably
affected by the advent of the very technologies that threaten the health care
status quo. Physicians continue to use therapeutic models and processes that
are resource intensive and often neither state-of-the-art nor cost effective.
The fact that U.S. physicians vary widely in their methods is, some writers
say, one reason why our health care is so expensive.11 Such variety
makes it difficult to determine which methods produce the best outcomes. As
genomic targets, new pharmaceutical agents, miniature medical devices, and futuristic
diagnostic tools become common, they will make methodological variety less tolerable.
If health care is to use new tools efficiently, it must reform its current services
and structures. Anticipating these new modes of delivery — and choosing among
them wisely and efficiently — will be a high priority in the planning and design
of clinical systems. Neither physicians nor hospital leaders can undertake this
complex and critical shift alone.
NOTES
- R. Herzlinger, Market Driven Health Care, Harvard Business School
Press, Boston, 1998, and R. Ayres, Turning Point: The End of the Growth
Paradigm, St. Martin's Press, New York City, 1998.
- Healthweek Outlook, July 30, 1999, pp. 42-63.
- C. Christiansen, R. Bohmer, and J. Kenagy, "Will Disruptive Innovations
Cure Health Care," Harvard Business Review, September 1, 2000, pp.
102-112.
- T. Porter-O'Grady, "Reengineering the Nursing Profession," Aspen's Advisor
for the Nurse Executive, vol. 9, no. 7, p. 6.
- M. Harry and R. Schroeder, Six Sigma, Doubleday, New York City,
2000, pp. 6-12.
- Committee on Quality in Health Care, Crossing the Quality Chasm,
Institute of Medicine, Washington, DC, 2001, pp. 1-6.
- R. Coffey, S. Stagis, and K. Fenner, Virtually Integrated Health Systems,
Jossey-Bass Publishers, San Francisco, 1997.
- P. Drucker, Introduction to The Organization of the Future, F. Hesselbein,
ed., Jossey-Bass Publishers, San Francisco, 1997, pp. 5-13.
- J. Meliones, "Saving Money, Saving Lives," Harvard Business Review,
November 1, 2000, pp. 57-67.
- R. Kaplan and D. Norton, The Strategy-Focused Organization: How Balanced
Scorecard Companies Thrive in the New Business Environment, Harvard Business
School Publishing, Boston, 2000.
- D. Vickery, "Toward Appropriate Use of Medical Care," Healthcare Forum
Journal, vol. 39, no. 1, 1996, pp. 14-19.