News :Hospitals at the Crossroads: What Does the Future Hold?

Posted on Monday, March 02, 2009

A perfect storm of economic, social, technological, and health care issues threatens the survival of hospitals in today’s competitive marketplace and challenges their viability for the future. Health Care at the Crossroads: Guiding Principles for the Development of the Hospital of the Future is a multi-disciplinary examination of the critical problems that confront U.S. hospitals today, while providing a blueprint for future change. Issued November 20, 2008 by The Joint Commission, the report presents the consensus view of a 45-member international panel of doctors, nurses, hospital administrators, educators, and other health care industry leaders. Dedicated to improving the safety and quality of public health care since 1951, the independent, non-profit Joint Commission is the primary health care standards-setting and accrediting body in the United States.

If American hospitals are to remain financially viable and still be responsive to America’s future health care needs, the Joint Commission report recommends action in five key areas: economic viability, technology adoption, patient-centered care, staffing, and hospital design.

Economic Viability. In 2007, Americans spent $2.2 trillion on health care, an average of $7,500 per person, according to the Joint Commission report. More than one-third of U.S. health care dollars went to hospital care, compared to 20 percent for physician services and 10 percent for pharmaceuticals. The cost of health care has placed an untenable burden on employers that are shifting costs to employees. Nearly 47 million Americans do not have medical insurance. High health care costs, economic factors, and increased demand as Baby Boomers enter the system are predicted to bankrupt Medicare by 2019.

These financial issues, coupled with the graying of America, are increasing the number of publicly-insured patients seeking hospital care, resulting in greater levels of uncompensated care that threaten the solvency of many hospitals, warns the report. Hospitals that traditionally rely on private payer income to offset money lost treating Medicare/Medicaid and indigent patients will find their position increasingly unsustainable as America’s population shifts from workers to retirees. The push toward value-driven health care, competition from specialty hospitals, and the lure of medical tourism are further depleting hospital funds.

For hospitals to remain economically viable, hospitals, government policymakers, and health care stakeholders must work together to improve the efficiency of America’s health care system and reduce costs. The current payment structure that favors health care payers must be rebalanced to allot hospitals the resources to fulfill their social mission to provide health care to all.

Technology Adoption. Digital technology will allow hospitals to expand care beyond their walls into the community and patients’ homes, predicts the Joint Commission report. Implemented in 2004, the U.S. Department of Veterans’ Affairs (VA) Care Coordination Home Telehealth (CCHT) Program serves as an example of future care models. According to the Joint Commission report, CCHT supports the home care of 33,883 patients and has reduced hospital admissions by 20 percent and hospital bed days by 25 percent. Remote patient monitoring and telehealth applications hold broad promise for the treatment of chronic diseases.

Implementation of a national electronic health data base similar to the VA’s comprehensive records system is considered critical to the development of a future hospital model defined more by intellectual property than location. Today, comprehensive electronic health records are maintained by only 11 percent of non-federal hospitals and 12 percent of physician practices.

The complexity of the U.S. health care system, lack of uniform national standards and the sheer cost of implementation – millions of dollars for a community hospital – have hampered the adoption of health information technology (HIT). Despite recognized improvements in patient safety and quality of care, HIT hasn’t provided sufficient return on investment to entice hospitals; and when HIT systems are not interactive with other systems, their usefulness diminishes. The Joint Committee report suggests that change will not come without federal direction and incentive.

Patient-centered Care. The growing emphasis on patient-centered care is reshaping hospital practices and policies, impacting the basic attitudes of health care practitioners, and changing hospital culture. Accepting patients as respected and equal partners in their care improves patient/caregiver communication, reduces medical errors, decreases the length of hospital stays, and increases patient and staff satisfaction ratings. “Engagement of patients and families empowers patients to participate in care decisions, provide self-care, and protect themselves from potential harm,” the Joint Commission report notes.

In a 2007 study by The Commonwealth Fund cited in the report, collaborative care that actively involved patients and their families in self-care and monitoring activities provided better control of chronic conditions such as blood pressure, blood glucose and serum cholesterol than traditional treatment. Chronic illnesses afflict more than 75 percent of adults over age 65, with many having multiple conditions, according to the Joint Commission report. Patient-centered care administered by a multidisciplinary team of health care professionals is considered the most effective method of combating this growing national health crisis.

Changing hospital culture to emphasize patient-centered care will require hospitals to enhance staff support. “Staff members need to be supported through systems that protect them from harm – and from doing harm,” recommends the Joint Commission report.

Staffing. The second major private-sector job provider nationwide, hospitals count among the top 10 employers in urban areas and the major employer in many rural areas, according to the Joint Commission report. Health care is one of the fastest growing employment sectors in the U.S., but supply can’t keep up with demand. A 2007 poll conducted by the American College of Healthcare Executives cited in the Joint Commission report ranked workforce shortages among the top five challenges facing U.S. hospitals.

“Pervasive staffing problems challenge the ability of the hospital to perform its most fundamental functions,” warns the Joint Commission report. High turnover rates among hospital executives challenge continuity. Fourteen to 18 percent of hospital CEOs and nearly half of nurse executives leave their jobs within a year. By 2020, an anticipated shortage of 85,000 physicians has the potential to significantly threaten U.S. health care services. The hospital vacancy rate for RNs was 8 percent in 2006 and continues to climb, although the poor economy is forcing more RNs back into the workforce. By 2020, the U.S. nursing shortfall is now predicted to be 340,000, half the previously predicted shortage of 760,000.

Hospital RN shortages are of particular concern. “Studies show that there is an association between registered nurse staffing and hospital-related mortality, failure to rescue, and higher risk of complications, among other negative patient outcomes,” according to the Joint Commission report. Nursing shortages affect patient satisfaction, reduce the number of beds available to serve patients, increase hospital stays and surgery wait times, and can force emergency department diversion.

Staffing shortages add to persistent low staff satisfaction at hospitals. Job dissatisfaction rates for hospital nurses are three to four times higher than the average U.S. worker. The turnover rate for new hospital nurses is 27 percent. Part of the problem is nurses’ changing role in health care. Nurses now find themselves spending nearly one-third of their time on paperwork instead of direct patient care. Other issues contributing to nurse dissatisfaction include long shifts, persistent fatigue, lack of empowering leadership, lack of support technologies, poor workflow and lack of voice in decision-making processes. Facilities that focus on strengthening nursing recruitment and retention efforts, such as those awarded Magnet Recognition by the American Nurses Credentialing Center, report higher levels of staff satisfaction, the Joint Commission report notes.

To serve patients with fewer staff, hospitals may initiate team-centered collaborative care. While reducing error levels, the Joint Commission report notes that team care requires education and training to be effective, which can further decrease time for patient care.

Hospital Design. Fueled by increasing demand for health care services and obsolescence caused by rapid advances in medicine and technology, the recent boom in hospital construction, slowed only slightly by current economic problems, provides an opportunity to redesign hospitals to better meet patient needs, improve patient safety, and create a supportive staff environment. Hospitals of the future must include standardization of systems and processes to reduce errors, multi-purpose adaptability to enable flexible facility use, robust utility capacity to accommodate expansion and new technologies, a plug-and-play infrastructure to prevent disruption of primary services during construction, and planned zones for future growth.

Hospital design must also consider the needs of an increasingly elderly patient population and the aging of its staff. The Joint Commission report recommends involving staff in the design process. Better lighting, reduced noise levels, decentralized nursing stations, standardized room design, and multi-acuity beds can improve patient care and safety. Single-bed rooms are mentioned in the report as the most effective way to reduce the spread of infection. As health care providers, hospitals also have a mandate to promote environmental health.

At the November 20, 2008 teleconference announcing the release of the Hospital of the Future report, Rita Gallagher, PhD, RN, the American Nurses Association (ANA) representative to the Joint Commission roundtable, stressed, “Nursing is the largest component of the health care workforce and provides the greatest amount of direct patient care, particularly within the hospital. It is important for all health care related initiatives such as the roundtable to include the perspective of registered nurses in order to transform the health care system.”
Sources:
http://www.jointcommission.org/NR/rdonlyres/1C9A7079-7A29-4658-B80D-A7DF8771309B/0/Hosptal_Future.pdf
http://www.jointcommission.org/NewsRoom/NewsReleases/nr_11_20_08.htm
http://www.jointcommission.org/
http://www.jointcommission.org/NewsRoom/PressKits/Hospital_Future/
http://www.aha.org/aha/content/2007/pdf/070508-boomerreport.pdf
http://www.aha.org/aha/research-and-trends/health-and-hospital-trends/2007.html
http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=468284#areaCitation

The following appeared in an issue of Maxim’s nursing eNewsletter, Nursing Now. To receive news in your e-mail inbox each month, sign up today