Changing Hospital Goals
By Robert M. Sigmond
The greatest need of hospitals today is the formulation of new concepts for a changing world. This can be achieved only through a new approach to planning. Formerly, we planned for buildings; now the challenge is to plan for change. Fantastic change in health care lies before us. The hospital must tool up to understand, anticipate, and adapt to change, and to give leadership in these changing times.
Later on, we must review together the nature of these impending changes in detail. The root causes of the changes are already with us: technological advances, increasing specialization, rising effectiveness of medical services, rising public expectations, soaring costs, and shifts in sources of financing. The key
issue in the health field for the next twenty years, for which we must begin to plan now is simply this:
How to deliver high quality comprehensive medical care to people at the prices they can afford to pay.
It will take years to shape a workable solution. We can and must solve the problem of delivering effective, economical health care. If we do not, the hospital will lose its autonomy.
A new style of planning is required to meet this type of challenge. The key feature is a new way of looking
at goals and at relationships between ends and means; a systematic and open approach to the interrelationships between goals of various elements of a system and the goals of the system itself,
and to evaluation of progress in achieving these objectives.
I. Introduction
What are the goals of a hospital? Has anyone or any committee at your hospital ever tried to formulate a precise statement of the hospital's goals since the time that the hospital's charter was filed with the Courts? As a matter of fact, do you really know what the hospitals legal documents set forth as the purposes of your hospital? Do your hospital's goals or purposes relate in any way to the health problems of your community?
In recent years, health planning agencies have been raising more and more questions about hospital goals. The modern style of problem solving advocated by planners involving such techniques as systems analysis and cost effectiveness is based on "arranging ends and means so that decision makers have clearer ideas
of the choices open to them and better ways of measuring results against both expectations and objectives." More open and deliberate attention to selection of the goals toward which action is directed is the essential first step in an effective planning process.
A few hospitals have undertaken a systematic effort to define their corporate goals. They found this task to be frustrating, difficult and time consuming. Those which have been successful have found that the result
was well worth the bother; the pay-off is unbelievable. After goals are formulated precisely, many knotty problems.especially those involving medical staff relationships, capital investment and community service can be seen in a new light that reveals acceptable solutions previously not seriously considered.
II.
Current Hospitals Goals
Many hospitals believe that they have well defined
goals, but analysis has indicated that these goals are hardly
ever expressed in terms of community service. Few have expressed
their goals in written form.
One must learn about them by questioning key officials.
The most common response is optimum patient care or high quality
patient care. Obviously, quality patient care is a necessary
hospital goal, but is it a sufficient goal? No hospital should
plan for second rate patient care or for high quality dog
care. Of course, high quality patient care, but for which
patients and what services? The necessary goal of high quality
patient care is meaningless in terms of planning the future
role of the hospital in relation to community requirements
and resources. It contributes nothing, because it reduplicates
a goal of every hospital. Furthermore, some hospitals especially
in urban centers appear to be striving for best patient care
by serving only the best patients. There is some evidence
that a narrow focus
on quality of service has interfered with hospitals' potential
to improve the health of the people.
The fundamental mistake is to set goals in relation to patients,
instead of people. Hospitals serve patients, but they should
plan in relation to people, both sick and well. This has been
well understood in statewide planning of beds for in-patient
care for many years. We provide a ratio of one bed per inpatient
served at any given time, but we plan a bed complement per
1,000 people, sick and well. Planning in relation to patients
ducks the issue.
Some hospital officials tend to define their goals in terms
of providing safe and comfortable accommodations and services.
Their building programs are designed to overcome fire hazards,
crowded conditions, outmoded facilities, leaky roofs, etc.
Again, necessary but not sufficient! Every hospital should
strive to provide safe and comfortable accommodations, but
this limited goal by itself does not provide a basis for community
support. Every other hospital is doing the same. None can
do less. Again, the statement of goals ducks the issue.
When questioned about long-range goals, some hospital officials
reply in terms of effective utilization
of facilities and services. Who can argue against this goal?
But, clearly, this is another necessary but insufficient goal.
Presumably, the hospital exists to serve the community; the
community does not exist
to serve the hospital. To imply that the basic goal is to
serve the facilities is to mix up means and ends.
At best, it assumes that the existing facilities the status
quo should be protected against the forces of change. At worst,
this approach ducks all consideration of community health
requirements altogether.
A pathetic example of this kind of planning is found in the
many ineffective steps taken by some hospitals recently to
improve use of their obstetrical facilities. The fact is that
investment in modernized facilities
and addition of more obstetricians to the medical staff usually
has very little influence on a declining
birth rate. Planning primarily in terms of maximizing use
of facilities involves the community in the kind
of circular process that can only lead to fundamental restructuring
of the system.
A fourth answer that is frequently provided with respect to
the goals of an individual hospital is in terms of meeting
the needs of the medical staff. Here, we are getting much
closer to the mark, for the physicians are the key to community
health service, the indispensable link between the hospital
and the community. In a real sense, a hospital's community
consists almost entirely of the people who look to that hospital's
medical staff for health protection. Clearly, one of the goals
of a hospital is to meet the needs of the medical staff.
But even this statement of hospital goals, although it points
in the right direction, in itself represents an insufficient
formulation of goals, for two reasons. First, in the absence
of a community-oriented formulation
of policy of the hospital with respect to future medical staff
appointments, the future relationship of the hospital to the
community is as vague as when the hospital is planning solely
in relation to optimum patient care. Like other people, physicians
retire, become incapacitated and die. A hospital which is
planning only
in relation to its existing medical staff is not engaging
in long-range planning.
Some may wonder why the single element of a policy on medical
staff appointments isn't obvious and
self-evident: appointment of the best qualified physicians
available. Unfortunately, the issue can't be
resolved that simply. Even assuming that the task of ranking
the quality of physicians can be carried out,
the fact remains that every hospital can't limit itself to
the best, if the needs of all people served by all physicians
are to be met. All licensed physicians should have appointments
at good hospitals, especially those physicians at the lower
end of any scale of quality. Affiliation with a good hospital
is the only effective protection the public has against incompetent
physicians. Each hospital has a responsibility to face this
issue in formulating its policy on medical staff appointments.
There is a second reason why a hospital runs into difficulties
by defining its goals solely in terms of meeting the needs
of the medical staff. Since World War II, the number of medical
staff appointments per physician in multi-hospital communities
has been rising at a rapid rate. Today, most physicians have
staff appointments at two or more hospitals. If hospitals
plan in terms of the total needs of their medical staffs,
the degree of duplication of facilities and services will
greatly inflate capital and operating costs and will result
in such
low rates of utilization of facilities and services as to
threaten quality standards.
In a situation in which the typical hospital finds that it
represents less than a majority of the medical staff appointments
of its own medical staff, it must develop a medical staff
appointment policy that involves consideration of the other
hospitals with which it shares its most important resource,
its physicians.
Other goals are reported by hospital officials who have been
questioned: fiscal solvency, institutional survival, prestige
for those associated with the institution, improved education
and research programs. As with the other examples given, detailed
analysis indicates that these may be necessary or desirable
but are insufficient goals for community service institutions.
The individual hospital has tended to view improved health
of the people in the community as an inevitable consequence
of fulfillment of other hospital goals rather than as a primary
goal in itself. There is little evidence that pursuit of the
specific goals mentioned above will automatically result in
improved health
for the people. Increasing evidence suggests not. As patient
care has become better and better because
of its increased specialization and mechanization, its component
parts have also become more and more fragmented and, in effect,
less and less accessible to the individual. The people in
need of care have increasing difficulty finding their way
to the right service at the right place at the right time.
While patient
care potential keeps improving, the gap between potential
and result appears to be widening.
In most hospitals today, there is no knowledge of community-based
health indices, no particular concern
for how well the community is doing. No one is assigned responsibility
for knowing: no one seems to care. From an analytic point
of view, the hospital is the key to community health, but
the hospital does not explicitly set its goals or programs
accordingly and therefore falls far short of its potential.
The current situation offers a striking analogy with the situation
that existed 50 years ago with respect to quality of care.
From an analytic point of view, 50 years ago the hospital
as an institution was the key to
the quality of care provided its patients. But the typical
hospital did not accept this obvious fact and did not develop
its programs accordingly. The individual physician was supposed
to be responsible for quality, the institution wasn't supposed
to have anything to do with it, except to serve the physician.
This was fine, except that it didn.t fit the emerging realities
for two reasons. For one thing, some physicians weren't as
good as some others, and needed supervision and control. But
more important, the physician couldn't function effectively
in an organizational vacuum. He needed the services of the
hospital organized in a coordinated, quality-focussed manner.
So about 50 years ago with physician leadership, mainly through
the American College of Surgeons, each hospital was encouraged
as an institution to face up systematically to its responsibility
for quality. When hospitals began to assume systematic, explicit,
corporate responsibility for quality, as a result of public
support of the efforts of the American College of Surgeons,
there was a major struggle in many hospitals. Many physicians
didn't really understand or accept the whole concept.
That struggle isn.t over yet in all the hospitals in this
country or among all the physicians. But today, it
is generally accepted that the hospital as an institution,
working through the medical staff not as a
collection of individual physicians, but as an organized entity
of the hospital is responsible for quality.
The same situation applies with respect to community health
today as with quality 50 years ago.
The hospital is obviously a major key to community health,
even though it does not pursue this goal as such.
The hospital should accept this goal and develop explicit
programs in terms of making the most effective contribution
to community health. Hospitals and their medical staffs should
begin to set their goals and restructure their programs accordingly,
before outside pressure becomes too great.
Here's the way the American Hospital Association put
it in a recent policy statement:
"The hospital, with its medical staff, is now the major
health resource in most communities. To meet the expanded
responsibilities of this position, it is essential that it
widen its concerns to include the totality of health services,
and with others, to provide leadership in their attainment.
The hospital should be prepared
to assume a primary position in the implementation of community
health plans. Each hospital, then,
through its governing body, medical staff, and administrator,
has a clear mandate continuously to
examine its organization and facilities in the light of this
central role in coordinating the principles of
optimum health services."
Any hospital which accepts the goal of optimum health services
can expect to become a unit in a multi-hospital network that
assumes responsibility for delivering a full range of coordinated
health services to a defined population. The term "hospital
care" will tend to disappear from the language as lacking
in meaning. Health care services will be provided under the
hospital's roof and elsewhere; all health care services will
be related in one way or another to the hospital and its medical
staff. The double standard with respect to quality of patient
care in and out of the hospital, will begin to disappear.
The hospital will be equally concerned with the quality of
the care received by patients before entering the hospital,
during their stay in the institution, and after leaving it.
The hospital will be at least as concerned with distributive
processes as with productive processes.
The hospital "room and board" services will be identified
as the true ancillary services ancillary to the diagnostic,
treatment, and rehabilitative inpatient and out-patient services
that will make up the basic services of the hospital.
The hospital will be concerned not only with getting the patients
out of hospital beds, but with keeping them out. Relationships
with health departments and with other health and welfare
agencies will be much more intimate and time consuming. Many
hospitals will assume landlord relationships with these other
agencies.
In the coordinated network of facilities that will evolve,
three distinct types of hospitals will emerge and establish
identity (although there will be many healthy mongrel specimens):
(a) A large number of hospitals will be identified
with a specific community, and will concentrate on distributive
processes. These community hospitals will place major emphasis
on prevention, early
diagnosis and treatment, and on affiliation arrangements with
other institutions for more complicated procedures and educational
programs.
(b) A smaller number of larger regional hospitals
will have more comprehensive service programs and
a secondary affiliation with a medical school complex. These
regional hospitals will provide service to
a group of nearby community hospitals with which they will
maintain close working relationships.
(c) A still smaller number of hospitals will
have primary medical school affiliations, a major commitment
to education and research, and will provide the most complex
services. These medical school hospitals will develop working
relationships with the regional hospitals to assure optimal
health services in their areas of influence. At the medical
school hospitals, major emphasis will be on productive processes.
Some of these multiple hospital systems or complexes may evolve
through merger under single management. In most cases, however,
autonomy of the individual institution will be preserved.
The system will function by a series of more or less formal
affiliation agreements, involving joint
medical staff appointments, cost sharing, joint trustee committees,
etc.
Although the overall goals at all three levels will be identical
comprehensive health services each will tend to place greater
or lesser emphasis on productive and distributive processes.
Each will be dependent on the others, however, and autonomy
for each institution will necessitate invention of formal
mechanisms for resolving constructive conflict among the different
units.
III. Implications of New Hospital Goals for the Medical
Staff
The emerging hospital goal of comprehensive health
care for the people in the community will eventually affect
almost every aspect of a hospital's medical staff, just as
did the emergence of the goal of quality.
Only the highlights can be suggested at this time. I will
briefly touch on nine points. You will think of others.
1) Basis for Evaluation of Performance. One
of the primary functions of a hospital medical staff is evaluation
of the staff's performance. Traditionally, this has involved
analysis of the records of the services provided in the hospital.
What is the hospital's death rate? The hospital's infant mortality
rate? The caesarian section rate? The infection rate? With
the shift in goals to comprehensive health of people, evaluation
will be based not only on hospital records, but also on community
records. What is the community's death rate? Its infant mortality
rate? What are the leading causes of death and disability
and what effect is the hospital having on these rates? Isn't
something wrong with the hospital's programs if the community's
infant mortality rate is rising while the hospital's is falling?
Does a rise in heart attacks only call for expanded coronary
care units
or does it also demand hospital-based programs to preserve
and protect functioning coronary arteries in
the community?
Can a hospital medical staff be satisfied only to foster tender
loving care within the hospital? Shouldn't it
also educate and motivate those who are potentially best qualified
to provide this essential ingredient of
good health: the consumers? Who could be more willing and
able to provide tender and loving care than
the individual himself? As programs reach out beyond the hospital,
so must techniques for evaluation of
their success.
Community-based evaluation requires agreement on the community
of responsibility. Today, the only practical approach is geographic.
Delineation of a service area can be based on analysis of
residence of patients and on location of offices of the attending
staff. The hospital's defined community can be large or small
in area and population. It can contain few or many other health
institutions. But some community
must be identified if a hospital's medical staff is to be
in a position to evaluate the impact of its activities in
the light of the goal of community health. This does not mean
that a hospital medical staff would not serve patients from
outside its community. Of course, it would serve anyone who
seeks needed care that the hospital is in a position to provide.
But it will direct its major energies to the problems of its
own community and will measure its success in terms of the
health indices of its own community.
In this context, other institutions serving the same community
are collaborators rather than competitors.
In general, it is preferable for a hospital to designate a
service area with relatively few other institutions,
since collaboration is time consuming and assessment of a
single institution's effectiveness is difficult in
a multi-hospital community. Merger may be the only solution
in the long run in some areas. But careful delineation of
interlocking responsibilities of affiliated institutions may
be a more practical immediate
answer. In any event, few medical staffs will be able to evaluate
their performance except in joint
programs with other institutions.
Hospital medical staffs will of course continue to evaluate
the specific activities of their members in the hospital.
But the staff will also be concerned with assessment of activities
outside of the hospital and
with evaluation of interrelationships with agencies not directly
under the control of the hospital.
2) Basis for Determining the Scope of the
Hospital's Services. With a new goal of comprehensive health
for the people in the hospital's defined community, every
hospital will recognize that it cannot provide all services
required by all of its patients and potential patients. To
achieve its goal, each hospital medical staff will have to
devote major energy to working out convenient and effective
continuing affiliations and relationships with other institutions
for those services which it does not provide itself. The key
to all such inter-hospital arrangements will be the medical
staff member with multiple staff appointments.
Patterns will emerge that will gradually identify formal classifications
of general hospitals: medical school hospitals, regional hospitals
and community hospitals. The Joint Commission on Accreditation
of Hospitals will develop interrelated but separate standards
for medical staff organization of each type of hospital.
3) Classification of Medical Staff Appointments.
Current terminology of staff appointments honorary, consulting,
active and courtesy does not have relevance to emerging hospital
goals. They will change to reflect the growing interdependence
among hospitals in meeting community health problems. Medical
staff appointments will be worked out jointly among two or
more institutions. The fundamental medical staff classification
will be into two groupings: basic staff appointments and secondary
staff appointments.
Every individual physician will have one and only one primary
appointment, which will be with that hospital
to which he looks for identification with community health
programs. In cooperation with the hospital, most physicians
will also work out one or more secondary staff appointments
at other hospitals. These may be "overflow" secondary
appointments to meet situations when the basic hospital's
facilities are overtaxed.
Or they may be "specialty" secondary appointments
to meet the physician's needs for specialty services
not available in the basic hospital, such as delivery rooms,
cobalt, teaching programs, etc. Or they may
be "consultant " secondary appointments to provide
specialized service or supervision in an affiliated
hospital lacking certain skills in its basic staff.
Allocation of duties, privileges and time will be worked out
by each physician in coordination with the hospitals granting
basic and secondary appointments, in order to assure a smoothly
functioning
coordinated hospital system and an orderly professional career
for the physicians involved.
Physicians with primary staff appointments will be subclassified
into those who are geographically full-time and those with
offices elsewhere in the community. Medical staff responsibilities
will be restructured so that geographic full-time men will
assume primary responsibility for control of quality and other
production processes while the community based physicians
will assume greater responsibility for control of the distributive
and delivery processes. A major challenge facing medical staffs
is this restructuring to
achieve appropriate channels for identifying, balancing, and
resolving constructive conflicts among
medical spokesmen for productive and distributive processes.
In doing so, old-fashioned general
practitioner-specialist and town-gown conflicts will be transformed
into entirely different and more
productive interchanges.
4) Criteria for Staff Appointment. New goals
will result in new criteria for staff appointment. The search
for the best men will be subordinated to the necessity to
attract all the licensed practitioners who are providing a
significant volume of service to the people in the hospital's
service area. To achieve its goals, the hospital has special
responsibility to bring in and influence physicians at the
lower end of the quality scale. Anne Somers' recommendation
that all licensed physicians be legally required to have a
staff appointment would be most helpful in this connection.
As all licensed physicians join the medical staff, the public
will have to be helped to understand that quality of care
is dependent as much on the quality of medical staff organization
as on the skills of the individual physician. But there is
much evidence that the public may be ahead of hospital officials
in recognizing that the era of the Great Man in medicine is
ending.
At any rate, more attention will necessarily be given to delineation
of privileges and to supervision, as less attention is given
to quality as a criterion for staff appointment.
5) Criteria for Education Programs. In the
past, justification to hospital trustees for expensive educational
programs for interns and residents often was the "rub
off" effect on the education and standards of the medical
staff itself. Increasingly, with new goals, the hospital's
educational program will focus more directly on the medical
staff, with house staff, if any, participating actively in
the hospital's continuing education program. More and more,
house staff will be viewed as colleagues, as part of the geographically
full-time staff, as integral members of the medical staff.
Narrowing of income differentials between house staff and
other medical staff will contribute to this trend.
House staff members will benefit from and approve of the shift
in emphasis by full-time and volunteer service chiefs to concern
for overall educational upgrading and organization of the
medical service as a whole.
6) Criteria for Research Programs. Hospital
sponsored research will inevitably shift its emphasis to study
of delivery patterns, patient care evaluation and results,
as contrasted to non-community, non-patient-related laboratory
and animal studies of problems only remotely related to the
activities of the busy hospital.
The idea that research any research enhances the quality of
care and prestige of a hospital will die a
slow death, but it will die.
Research goals will be related to hospital goals. Hospitals
will become major centers of research in community health
and medical care.
7) Increased Medical Staff Concern for NonInstitutional
Care. The broadened goal of comprehensive health for people
will inevitably involve the hospital's medical staff much
more deeply in systematic approaches to care of ambulatory
patients and homebound patients.
There are almost limitless opportunities for the hospital's
personnel and facilities to be as helpful to physicians in
serving these patients as in serving inpatients. Conservation
of physician time his and the community's most precious health
resource will be the key to most effective community health
programs.
Much of the activity of nurses in intensive care units, for
example, requires more professional skill than does much of
the activity of a physician seeing upper respiratory infection
cases in his office. A great burden of unchallenging work
can be lifted from physicians' shoulders if they insist on
as much help from hospitals with their ambulatory and homebound
patients as with their in-patients. This can be facilitated
as physicians work more closely together in hospital-based
office facilities. Pediatricians, psychiatrists and obstetricians
are likely to lead the way in this development, but others
will not be far behind.
8) Promotion of Free Choice of Private and
Service Arrangements. In the past, hospitals offered two classes
of care private and clinic service-dependent in most hospitals
on the ability of the patient to pay. But many affluent patients
like those attending the Mayo Clinic-preferred clinic service
to selecting their own private physicians. And as most practitioners
know, many poor people preferred private service to clinics,
even if it meant large unpaid bills. With Medicare and Medicaid
and other programs, the ability-to-pay distinction between
clinic and private service seems to be obsolescent. But many
hospitals may be expected to continue to offer both types
of service on a free choice basis with many physicians, as
in the past, serving in both capacities. As many of the poor
move from a clinic to a private physician relationship they
could never before enjoy, many of the affluent will shift
from a private to a clinic relationship that they could never
before enjoy. Many new organizational patterns will emerge;
much will depend on the ingenuity of medical staffs
in adapting to new forces.
9)
Administration of Fee-Splitting. Traditionally, one of the
most important medical staff functions has been to stand in
the way of fee-splitting, because of the threat to quality
of care that this practice represented. With broadened goals,
the medical staff will re-evaluate this situation and will
itself jump into fee-splitting with both feet. In the new
health care world, controlled fee-splitting is the only alternative
to abandonment of fee-for-service payment altogether. Unsavory
fee-splitting will be controlled by medical staff involvement
in administration of a variety of "ethical" fee-splitting
arrangements rather than by outlawing the whole practice.
Fee-splitting administration is already a major responsibility
of many medical staffs in connection with Title XIX patients.
IV.
Conclusion
A goal is the result or achievement toward which
effort is directed. Our goals represent our view of the future
toward which we are heading. In the past, a hospital has been
judged by its great physicians, by its number of beds, teaching
program, ancillary services, or massive buildings. When it
comes to judging a hospital for massive community support
from here on out, the key criteria will be its goals.
The hospital that is able to formulate sound community-oriented
goals is in contact with the health care realities of today,
is sensitive to changing forces and is probably effectively
organized to help the community achieve better health. Such
a hospital will attract far stronger community support than
one which has not been able to achieve a consensus on realistic
community health goals. The hospital which has not formulated
written goals at all will be as backward as a hospital without
a functioning medical records committee. Community-oriented
goal formulation is extremely difficult and time consuming.
The time to
start on it is now.
References
1.
Ways, M.: The Road to 1977, Fortune 75:93-95 (Jan.) 1967.
2.
Derbyshire, R. C.: What Should the Profession Do About the
Incompetent Physician? JAMA 194:1287-1290 (Dec. 20) 1965.
3.
American Hospital Association: Statement on Optimum Health
Services, Publication S-17, 1965.
4.
Rorem, C. R.: Progressive Patient Care, Health and Hos-pital
Planning Council of Southern New York, Inc., 1968.
5.
Somers, A.: Personal Communication.