Thirty years ago, who imagined scores of specialty surgical hospitals competing with acute-care facilities?
Twenty years ago, who imagined hospitals with all private rooms? Ten years ago, who imagined hospitals retaking the upper hand from managed-care organizations?
All those things are widespread in the hospital industry of 2003. What developments that we have a hard time even imagining today will be common 10 years from now?
This week, a conference in Washington will peer into a crystal ball, looking for an answer to the question: What will the community hospital of the future look like?
The Council on Health Care Economics and Policy is the main sponsor of "The American Hospital: What Does the Future Hold?" The conference is scheduled for April 21 in Washington.
"The most important question in healthcare is about the role of the hospital," says Stuart Altman, the council's chairman and the Sol C. Chaikin Professor of National Health Policy at Brandeis University in Waltham, Mass.
It's a critical time to try to find an answer to that question, Altman says. Hospitals have seen some underlying trends turn around, with admissions rising and average length of stay leveling off, so "a lot of people are talking about the capacity needs," he says. Amplifying those trends is the aging of baby boomers into the time of life when hospital use is greatest, he says. At the same time, the hospital industry faces labor shortages and difficulty in obtaining capital, Altman says.
"It's important to take a look at whether these expectations and predictions make any sense," Altman says.
Some well-known observers of the healthcare industry will be helping Altman make sense of those predictions, including Uwe Reinhardt, a professor at Princeton University, and Richard Clarke, president and chief executive officer of the Healthcare Financial Management Association, Westchester, Ill.
Other backers of the conference include the California Healthcare Association, the Center for Studying Health System Change, Cigna Corp., the Federation of American Hospitals, General Electric Medical Systems, Health Affairs and Johnson & Johnson.
Noticeably absent from the list of sponsors is the American Hospital Association, whose constituency is the subject of the meeting. The AHA is aware of the conference, says AHA spokeswoman Alicia Mitchell. The federation kept the AHA informed as the planning of the conference proceeded, she says. Mitchell notes that the AHA's annual membership meeting, scheduled for April 26-29, is a large undertaking that draws 2,000 healthcare executives.
Altman offers a word of caution, too. "One thing that we need to be sanguine about is (that) our ability to predict the future has been wrong more than it's been right," he says.
Switch to offense
Jeff Goldsmith roiled many in the industry with his 1981 book, "Can Hospitals Survive?" Goldsmith will kick off the conference with a look at how hospitals managed to survive in the past two decades, and his talk will partially prove Altman's point about predictions.
Goldsmith, who runs the Health Futures consultancy in Charlottesville, Va., says his book was right that ambulatory facilities, particularly for diagnostic and therapy services, would divert patients from hospitals and that improved home health services would help patients who did need to be admitted leave the hospital sooner.
What he acknowledges that he didn't foresee was how well hospitals would play defense.
"The hospital share of healthcare spending fell 10 percentage points since the early 1980s, to about 31%, even as the dollars have quintupled," Goldsmith says. "Hospitals have succeeded in defending their franchise. I argued that they had to go on the offensive, but they played brilliant defense."
Goldsmith argues the merger strategy that resulted in larger systems was just the defense to counter the offense of HMOs and their designs on rationing hospital use. He even thinks that the costly frenzy of acquiring physician practices in the 1990s defended hospitals from the physician-practice management model. "I think hospitals were the reason that model collapsed," he says.
But Goldsmith contends that defense alone won't cut it anymore. In particular, hospitals need to play offense with their biggest challenge-the recruitment of physicians, nurses and other credentialed staff when those workers are in short supply.
"I think the breach with professionals-morale, recruiting and retention problems (and) fights with medical staff-are big hurdles," he says. Hospitals also need to improve their ability to embrace new medical technology and to understand and truly gain from investments in information technology, he says.
"There are tremendous opportunities to improve efficiency and safety," he says. "I've been perceived as a critic of the hospital industry, but this is a very upbeat talk."
Not just an exercise
Greg Rusnak has been looking to the future for months now. Rusnak, chief operating officer of not-for-profit Greenville (S.C.) Hospital System, has been at the forefront of the system's development of a potential 120-acre medical campus in Greer, S.C. The three-hospital system expects to build a 110-bed hospital on the campus, supplemented by wellness and ambulatory centers and a skilled-nursing facility.
All of it is being designed around the idea that baby boomers have changed the way every business serves consumers, and healthcare will be no different, Rusnak says. "The volume of these patients at this age group is nothing like we've seen before," he says. "They probably understand their health better than any other generation previously but also probably are more demanding in the delivery meeting their needs, rather than them meeting our needs."
Delivery has to be more efficient, he says, because baby boomers are "not going to be very patient with long waits that we've typically seen in (emergency rooms) and physicians' offices and diagnostic centers."
Another design concept for the planned hospital is to give patients more control of their room environment at bedside, such as the ability to flick light switches on and off and to open or close the curtains, Rusnak says. It's a part of the Planetree philosophy that the Greenville system has adopted, he says.
A greater demand for chronic care figures to be part of the equation, too. "We also expect this population to live longer," Rusnak says, "so there may be needs that we don't even think of today." To that end, Rusnak sees the need for a long-term acute-care hospital unit and expanded skilled-nursing, adult day-care and assisted-living options on the proposed campus. "I think the focus is really going to be on filling in those gaps and managing the transitions for the patients," he says.
Workforce and technology
It's not just the patient profile that Rusnak expects will be getting older. The staff, particularly nurses, also is expected to have a higher average age. National studies peg the average nurse at 46 years old, Rusnak says, and that figure is expected to climb, so the hospital's design will take that into account to make it easier for nurses to continue working as they age.
Starting from scratch, of course, the hospital would be able to integrate a lot of technology designed to ensure good clinical outcomes, Rusnak says. For instance, nurses would wear devices that would prompt them to dispense medicines to their patients. The device would continue the prompting until the nurse documents that the patient ingested the medicine, he says.
All of this technology leads the Greenville system to conclude that unless there's demand for at least 100 beds, it won't be worth building an acute-care facility on the Greer campus, Rusnak says. A hospital's overhead costs, especially for technology, and the volume needed to support specialty physicians make 100 beds "a critical break point," he says.
In the Western U.S., John Hummer is dealing with a pleasant surprise. Hummer is CEO of 112-bed MountainView Regional Medical Center in Las Cruces, N.M. The hospital, owned by for-profit Triad Hospitals, Plano, Texas, opened last August, and already it needs to add four operating rooms to the six it had when it opened, Hummer says.
This surprise came despite two years of planning. The hospital does have a lot of capacity flexibility built in, as there is room to add another 60 beds, Hummer says.
Although Las Cruces and the surrounding Dona Ana County area had 180,000 residents but just one hospital, Hummer says, "we didn't get caught up in the demographics." It wasn't until they gauged the interest of physicians and, in a survey conducted by the Gallup Organization, the public at large that the decision was made to go forward.
Those operating rooms that were built are bigger to enable them to easily hold added equipment, Hummer says.
The flow of patients through the hospital is designed to allow them the greatest amount of dignity and privacy, Hummer says. There are two sets of elevators-one set at the front of the hospital for visitors and one set used to transport patients around the hospital for tests and procedures-so patients don't have to mix with visitors.
Larger waiting rooms
In addition to featuring all private rooms, the patient floors have large waiting rooms because Triad officials found that Las Cruces featured a high proportion of large, extended families, Hummer says.
The 2000 census reported the average size of a family in Dona Ana was greater than the averages for New Mexico and the U.S.
The hospital also has a wireless computer network that allows nurses to wheel their computers from room to room and electronically document patient evaluations right from the bedside, Hummer says.
Also, all supplies are bar-coded. Nurses carry a wand that reads the bar codes and automatically records the supplies used for each patient, which automates both patient bills and supply inventories, Hummer says.
Hummer cautions that the forward thinking has to extend to how you design the culture of a hospital, too. Ensuring that all employees-about 500 so far-fit that culture is important, he says. Employees and physicians must be given the chance to help develop the operational processes that the hospital will use.
"You can't just look at the bricks and mortar and the technology," he says. "That's not going to make you successful. It's important, but it's not the most important thing."
What do you think?
Write us with your comments. Via e-mail, it's [email protected]; on the Web, use modernhealthcare.com; by fax, 312-280-3183; or through the mail, Modern Healthcare, Letters to the Editor, 360 N. Michigan Ave., Chicago, Ill. 60601. To publish letters, we need your name, title, affiliation, location and phone number.