1. The Role of the Hospital in a Changing Environment Bulletin of the WHO, 2000,78(6) Martin McKee & Judith Healy LSHTM, London By: Keerti Bhusan Pradhan keerti@aravind.org

2. Summary Hospitals a challenge in Healthcare Reform Evolving role of hospitals Changing Healthcare Needs Emerging Technologies Size and Distribution of hospitals

3. Essence of the Article Hospitals must continue to evolve in response to factors Changing healthcare needs Emerging Technologies

4. Key Reform Strategies Behavioral Interventions-Quality Assurance Programs Changing Organisational Culture Use of Financial Incentives

5. Reform Challenges Hospital Buildings, Designs Hospital functions Barriers to change

6. Crucial Questions I. Why are hospitals created? Has the growth in knowledge & technology invalidated the 19 th century foundations? What do we mean by Hospital? II. If hospitals are to be integral parts of healthcare system? What should they look like? How should they be distributed? What should they look like inside? How can hospitals be designed in ways that enhance their performance (outcome & economic)

7. Questions……… Why do some hospitals seen to work well where as others not? How can hospital performance be optimized? Hospitals are not black boxes but are complex adaptive human systems

8. Why Hospitals? Changing pattern of diseases Changing life style Changing environment Technology advancement Clinical specialties Financially-50% of overall healthcare expenditure is for hospitals Organizationally-Dominate the health care system Symbolically-viewed as main manifestation of healthcare system

9. Challenges Scarce resources in terms of skilled staff and equipment hence needs concentrated facilities. Not dispersed across small facilities To provide care rather than cure. Care requires people rather than equipment, generalists rather than specialists. Access is more important

10. What Should a Hospital Look Like? Configuration of hospital services-Centralized or Dispersed Centralized-High volume-Better outcome and Economies of scale Dispersing Hospital-Improves access and reduces inequalities

11. Greater Volume-Better Health Outcome Practice make perfect Selective referral Greater specialization than the size Process of care is important than just the outcome Physician volume or Hospital Volume (Collective expertise of the entire team)

12. Economies of Scale & Scope For Concentration Large hospitals (200-400 beds) Different specialties under one roof Links between different specialties Optimal use of expensive equipment Against Concentration: Reduce access to care Access is more important in primary care, out patient services and screening programmes

13. Improving Clinical Performance Incentives for optimizing clinical performance -Quality Assurance Models -Clinical Audit -Clinical Governance (Managerial and Clinical responsibility) Clinical behavior is resistant to change No change following conferences/short educational events Behavioral change-Range of interventions

14. Organizational Environment Relationship between organizational culture and quality of care Better relationship b/w Doctors and Nurses Organisational and Professional job satisfaction Patient centered culture Effective collaboration Open approach to problem solving

15. Changing payment mechanisms The ideal mechanism would be one that offered incentives for producing effective, efficient and equitable treatment, with no perverse incentives and with minimal transaction costs A perfect system is not achievable, since there are inevitable tradeoffs Financial incentives, while good at pushing behavior in a certain direction, are less good at putting limits upon financial motivation

16. Looking ahead What the hospital of the future should look like? Will we still need the hospital or can its functions be performed elsewhere? Factors-Changing burden of disease Emergence of previously unknown disease Size of the workforce in healthcare Development in Technology

17. Hospital of the Future The hospital of the future must respond to all these challenges. It must balance economies of scope with optimal access, drawing on advances in technology. It may need fewer beds, but it will need more operating theatres and recovery areas……… The hospital need to be flexible, because the diseases it treats and the ways in which it treats them will be very different from those of today