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that effort, health professionals can only insulate the individual from the more catastrophic results of his ignorance, self-indulgence, or lack of motivation." 5
By all means let us discuss medical care. By all means let us discuss the costs of medical care. But above all, let us discuss them in relation to the more fundamental objective-better health.
H_"ORGANIZATION FOR THE DELIVERY OF CARE".
A STATEMENT BY ROBERT M. SIGMOND, EXECUTIVE DIRECTOR, HOSPITAL PLANNING
ASSOCIATION OF ALLEGHENY COUNTY, PITTSBURGH, PENNSYLVANIA, AT NATIONAL CONFERENCE ON MEDICAL COSTS, JUNE 27–28, 1967, WASHINGTON HILTON HOTEL, WASHINGTON, D.C.
During the past year, I have been conducting an informal, unscientfic, unstructured, confidential survey. I have presented dozens and dozens of practicing physicians with the following hypothetical suppositions and questions :
Suppose this country faced a major national emergency like a long world war that required your region to contribute as many physicians, nurses, and other health workers as possible. Suppose further that you were placed in charge of the health services in your region and were assured of the complete trust and cooperation of everyone. Would you be able to contribute any of the region's physicians, nurses and other health workers for national emergency service, without impairing the quality of the health service provided in your region?
Every single individual whom I questioned believed that if he could achieve complete cooperation and commitment, health manpower in his region could be substantially reduced without impairing quality of care and without adverse effect on the people's health. The unanimity of response was striking.
Even more striking were these physicians' responses with respect to the amount of reduction in health manpower that could be achieved without reducing the quality or effectiveness of service. When asked to estimate the proportion of the region's health manpower that could be released for national emergency service, the answers varied from about ten per cent to forty per cent, with an average of about 20 per cent.
Equally as striking was the conviction of most of these doctors that the greatest proportion of health manpower could be spared among the most highly trained health personnel-physicians and nurses, for example, as contrasted with aides, orderlies and kitchen workers.
How would manpower reductions be achieved? As you might expect, there was a variety of responses, but there was a surprising consistency of basic themes:
(1) grouping physicians (and other practitioners) in organized settings and centralized locations so that they can make full use of lesser skilled but specially trained workers in their "office practices” and thus provide more service per physician,
(2) locating more physicians' offices at hospitals and removing the distinction between "office" and "clinic" to reduce physician travel time and to permit full use of the hospitals' manpower and technical resources without having to admit patients as bed patients,
(3) redefining many health service tasks so that lesser trained personnel can take them on, such as passing more professional nursing duties on to well-supervised practical nurses and aides, and increasing the use of dental assistants,
(4) permitting nurses to make house calls in medically supervised home health programs,
(5) creating closer linkages among related hospitals to permit grouping of maternity, open heart surgery, and other specialized low use services at fewer larger hospitals,
(6) encouraging all families to develop more efficient medical care habits by identifying with one nearby physician group for provision and supervision of all needed health services.
'J. Douglas Colman, "National Health Goals and Objectives," speech presented at the National Health Forum, Chicago, Illinois, March 20, 1967.
Other ideas were mentioned less frequently: automation and computerization, self-help units in hospitals, intensified health education, multiphasic screening, etc. No one in the group suggested any lengthening of the work week.
Almost all of the physicians with whom I spoke focussed on the hospital as the key to manpower conservation. Almost all suggested grouping physicians at hospitals, and almost all pointed to the need to develop an interrelated network of smaller and larger hospitals. These physicians knew little or nothing about systems analysis, but all tended to think in terms of improved delivery systems as the key to manpower reduction.
How would my group of doctors go about organizing to bring about these changes so as to contribute health manpower to the national emergency? Almost all thought that they would work through the hospitals and their medical staffs or through the county medical societies. Some thought that they would start by drawing up detailed systems and manning tables for each hospital or county medical society to follow. Most, upon reflection, concluded that there were plenty of physicians and administrators in each community who would have as many ideas on how to conserve manpower as they had, and that detailed prefabricated plans were not necessary. All that would be required would be to assign specific responsibility in each community, and to encourage the leadership in each community to attack the problem in realistic ways.
Interestingly enough, many of the doctors whom I asked felt that the process of reorganizing to reduce manpower could produce improved quality with fewer health personnel. All agreed that since manpower is the largest part of health care costs, a 20 per cent reduction in manpower would result in reduction in the total health care bill.
In my informal, unscientific survey, I sometimes posed some final suppositions and asked one last question: Suppose the great national emergency was not a long world war, but the spiralling cost of medical and hospital services and the many unmet health needs right in your own region, the deaths and suffering that could be avoided by expanded and improved health service. Suppose further that the health workers that you could release for a great national emergency could be assigned right in your own region to work on reducing death and disability. Could you deliver? I wish that I didn't have to report that most of my group doubted that it would be possible, under current circumstances, to achieve the degree of commitment and cooperation that would produce results. At least, as a number said, "not in my lifetime".
I submit to you that any number of more highly scientific surveys of this type would document substantial consensus in the health field on two points. First, despite all the fatalism about inevitable costs increases, it is commonly accepted that costs could be reduced markedly without impairing quality. Second, the key to cost reductions is introduction of more systematic approaches to delivering comprehensive health services by grouping physicians and other practitioners in conjunction with hospitals and ancillary health personnel.
The time has come to convert consensus into operating programs that will bring results. What are the obstacles to achieving a more systematic approach? The lack of agreement as to which is the best way to organize the system shouldn't be a major obstacle because there is a wide variety of valid configurations, each of which could represent more systematic delivery of services and lower costs with better quality. The real obstacles, I submit to you, are the lack of commitment to community-wide goals within the elements of the system, the lack of a tradition of trust and cooperation, the lack of focus on systematic objectives, the lack of mechanisms for orderly corporate planning, and the lack of incentives for encouraging and assisting each element of the system to define an appropriate role for itself in relation to over-all goals and objectives.
In our extremely complex and pluralistic health care establishment, improved delivery systems will result from a refocussing of goals, programs, and interrelationships by every health agency, all up and down the line. What is needed is vastly improved planning by every health agency, in the framework of comprehensive health services for people.
The basic weaknesses, which can and must be overcome, are in the planning processes of health agencies. If the planning processes the ways that health agencies define goals and objectives and devise programs to achieve their objec. tives—are strengthened, the delivery system will be strengthened. The problem isn't that the main health institutions are performing badly; the problem is that the medical care programs in a community are so rarely worked out in the context of the defined needs of a defined community. The basic fault is in the planning process at each institution which programs health services. The solution is to improve the planning processes of all health units. I suggest that an orderly investment in strengthened planning processes in time could achieve the same impact on community health care costs as a great national emergency. The Allegheny County approach
A demonstration of improving a community's system of delivery of health care by improving each health agency's planning process has been underway for the past seven years in Allegheny County, Pennsylvania, encompassing the greater Pittsburgh area. The results so far are not dramatic, but a great deal has been learned. The "process approach” is becoming increasingly understood and accepted, and there are indications that a foundation has been laid for more rapid progress in the future.
Ten years ago, Allegheny County's health services looked pretty good. Each health care unit was striving for best care for its patients, for self-sufficiency, for fiscal solvency, for expanded service volume, for modern facilities, for its share of the County's limited health personnel and dollars. Each was quite sure that what was good for the institution was automatically good for the community. This approach had produced rapid growth and fine results for many past decades when health services were so inadequate and so uncomplicated that problems of duplication and lack of coordination were unheard of. By the late fifties, however, some community and professional leaders were beginning to question whether this approach made sense in the rapidly evolving, highly developed, complex health care field.
The hospitals—the major health care agencies were the first to recognize the problem. They began to perceive how poorly their individual planning efforts related to changing community needs and resources. They began to recognize that their individual uncoordinated planning efforts added up to less than the best health service, to pointless duplication and needless gaps, to waste of money and personnel, and to the very real risk of losing community confidence.
Let's take a closer look at today's hospitals. They are no longer simply edifices wherein sick patients lie in bed. They are no longer simply institutions that give doctors the tools to diagnose and treat certain kinds of illnesses. They are no longer simply the organizational entities that bring intra-professional discipline and education to doctors. They are all of these things, to be sure, but most importantly, they are increasingly becoming the key resource for community health services. They are the chief resource for organized medical care, the main focus for the technology and the group skills that are part and parcel of modern clinical medicine. They are the agencies with the strongest potential capability to create medical care programs that are directed at community health needs. More and more, however, people are questioning whether the traditional approaches to planning by the hospitals are suitable in today's scene. Planning at each hospital has tended to be facility-oriented and has only rarely engaged the full attention of the key professional component: the medical staff. Frequently, the planning has been sporadic and directed at short-range internally oriented goals. All too often the board of trustees has been preoccupied with means-construction and capital needs-rather than ends. Only rarely have administration, board, and medical staff been organized to carry on sound corporate planning for the hospital.
In 1960, our local hospitals stimulated the establishment of the Hospital Planning Association of Allegheny County, a non-profit community organization charged with responsibility for developing a flexible coordinated plan for hospital development. Prior to the formation of the Association, the hospitals were planning. The problem was not lack of planning. The problem was that the planning was almost entirely within an isolationist institutional framework, was not sufficiently responsive to rapidly changing professional and social forces, and only rarely included a systematic approach to setting goals and devising programs to accomplish the goals.
The Hospital Planning Association has been trying to provide encouragement, incentive, and assistance to individual hospitals in structuring planning proc. exses to meet community needs and objectives, and to help hospitals to plan together in terms of comprehensive health service. The main emphasis has been to stimulate an effective planning mechanism at each hospital. The Association provides many kinds of assistance in the planning efforts of each hospital and other health agency (including groups interested in establishing new hospitals). Finally, through a formal Approval Procedure, hospital capital proposals are endorsed by the Association board of directors, using criteria focussed primarily on the planning processes that produce the proposals.
The Association's criteria require that each hospital be established or expanded solely in terms of community need rather than the needs of the institution. Definition of community need requires a determination of what people the hospital is planning to serve, and what services it is planning for these people. Whether its programs are geared to primary health services or to specialized services, this requires that the hospital do its planning for a geographically defined community. The criteria require each hospital to delineate a geographic service area.
No one is suggesting that the hospital cannot serve patients from outside of its defined geographic area. There is no implication that the hospital should erect a Berlin Wall around its service area to try to prevent residents of the area from going to unrelated hospitals. Freedom of choice is preserved. But successful implementation of the hospital's plans should result in a higher and higher percentage of the hospital's patients coming from the defined service area, as more and more residents of the area identify with the hospital, its medical staff, and the inter-hospital relationships which develop.
What services should the hospital plan to meet the needs of the people in its defined service area ? Here the Association's criteria provide a very simple and clear guide. The hospital should plan for comprehensive services. This includes all services: not only general medical and surgical, but also psychiatric, rehabilitative, social service, home care, extended care, preventive, diagnostic, emergency, other ambulatory, etc.
No hospital can provide comprehensive services. But each can plan in terms of the comprehensive health needs of its service area, both by direct provision and by making arrangements with other institutions. Effective and efficient arrangements to make available comprehensive care for the population of the hospital's service area is the ultimate goal. This requires that, in developing its plans, the hospital should give at least as much attention to the service it will not provide as to the services that it will provide. Only in this way can orderly systems for comprehensive care be assured for the people.
The Hospital Planning Association places greater emphasis on planning process than on planning content. Building programs and staffing patterns are treated as elements of implementation which flow out of the functional plans that emerge from efforts to meet the Association's basic criteria. If a hospital is organized to plan effectively, and if its plans are demonstrably couched in terms of meeting the comprehensive health needs of a defined population, the criteria have essentially been met.
A major challenge to the Association is the fact that most hospitals are not organized for a systematic planning process related to community needs. Active involvement and interaction of the entire hospital family, especially the medical staff, are required if the hospital is going to be able to carry on corporate planning which is responsil to medical progress and which is based on viable goals.
Therefore, the key step is to achieve a viable organization of the planning process at each hospital. In Allegheny County, the hospital and medical leadership have decided that responsibility for the planning process at each hospital should be assigned to a new committee, called the Long-Range Planning Committee. This mechanism has since been picked up by many areawide planning agencies in the United States.
The Long-Range Planning Committee consists of representatives of the hospital's board of trustees, medical staff, and administration. Its task is very difficult and time-consuming, and requires staff support. In most hospitals, staffing can be provided by the hospital's regular administrative team, but three of our larger hospitals have now employed full-time planning directors to staff this committee. A fourth has sub-contracted with one of these large hospitals for planning staff services. Others have employed professional consultants to help.
Candor forces me to admit that progress has been very slow. Some hospital officials have had great difficulty applying the Association's concepts to their own institutions. There have been those who have rejected the Association's approach, or who haven't really believed that the Association was seriously committed to what it said. In seven years, two building programs have gone ahead without the Association's participation. The process of disseminating the agency's viewpoint is a continuous one, requiring endless hours of meetings, conferences, and other forms of communications. Hospital Long-Range Planning Committees have tended to be preoccupied, understandably enough, with their own institutions' pressing building needs. They have frequently put off discussion of comprehensive care and the difficult issues involved in relating medical practice to institutional service in meeting community needs. It continues to be difficult for many hospital officials to understand why an institution with high occupancy, high standards of patient care, and a worn-out building cannot proceed to replace the old building without a lot of frustrating talk about goals and comprehensive care.
Moreover, an infrequently mentioned but widely recognized fact is that hospitals, in developing the instutional pride that underlies the pursuit of excellence, have tended to develop deep-seated distrust of their neighboring, "competing" hospitals. With a long history of competition for self-sufficiency among autonomous institutions, there is a legacy of misinformation, a lack of trust, and memories about apparent past immorality and double-dealing which cannot be overcome overnight.
The only answer to this problem is better communications within institutions and between institutions. Open communications can create conditions of mutual understanding and trust which will permit much more effective planning.
The Association's approach requires a great deal of patience and fortitude. When carried out aggressively, it is deeply disturbing to the community, the institutions, the medical profession, and the staff and directors of the Planning Association. Over time, however, ignorance, apathy, disbelief, and opposition have receded. The Association's Administrators' Advisory Committee has recently re-affirmed the planning criteria. Its Medical Advisory Committee has become deeply committed to and involved in the Association's activities. Both committees are currently working on more detailed recommended guidelines for use in applying the planning criteria. Some hospitals still want to build first and plan later, but they can expect little support from the two advisory committees.
Specific results are beginning to appear. One community hospital, for example, which had had difficulty in accepting the service area concept, is now working closely with its immediate community-a poverty area-and has just received a $1,800,000 federal grant for a neighborhood health center to be operated jointly with community representatives. A large center city hospital has shelved its plans to compete in providing specialty services with all hospitals in the area. It has recast its program to become a coordinated specialty resource to the commnity hospitals in a section of the region as well as a primary resource to a Dearby poverty community. It is working to strengthen its neighboring hospitals through joint programs in specialty services. Other examples can be cited. Two hospitals have grouped their maternity services at one location. Four hospitals hare formed a joint corporation which is now operating a central pharmacy service, a central clinical chemistry laboratory, and a joint laundry, each of which serves hospitals not in the corporation. Seven other hospitals serving another section of the region have recognized their community of interest and have formed a joint corporation for coordinated policy making, and for operating joint programs. In both of these corporations, the participating hospitals have not surrendered legal autonomy. But as they work together on common problems, they tend increasingly to adopt common or interrelated positions. The Hospital Planning Association assisted in the creation of a Regional Medical Program which is beginning to function to promote and fund cooperative arrangements in the fight against heart disease, cancer, stroke and related diseases. Countywide approaches to emergency care, to home health services, to rehabilitation services, and to mental health services are in planning. Several hospitals are developing innovative joint approaches to ambulatory services, social service, and radiation therapy. Physicians are becoming more deeply involved in planning at their own hospitals. Discussions concerning comprehensive care are becoming more common and less charged with emotion within hospital staffs and among groups of hospitals. Implications of the Allegheny County experience
The Allegheny County experience suggests that delivery systems can be improred with reduced costs for comparable service, or better yet, improved service for less than it would have had to cost-by concentrating attention on