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Joint Commission paints detailed picture of 'Hospital of the Future'
Five core areas identified as targets for improvement
The project was nothing if not ambitious; The Joint Commission assembled a blue-ribbon roundtable of experts — hospital executives, clinical leaders, and experts in technology, health care economics, hospital design, and patient safety — and tasked them with analyzing how socio-economic trends, technology, the physical environment of care, patient-centered care values, and ongoing staffing challenges will affect the hospital of the future.
The result was a white paper entitled, "Health Care at the Crossroads: Guiding Principles for the Development of the Hospital of the Future," which discusses in depth the five core areas that will have the greatest impact on shaping the hospital of the future, and principles that health care leaders should follow to achieve the outlined goals. (A complete list of these areas and principles can be found here. The entire white paper can be downloaded at www.jointcommission.org.)
So, how will the "hospital of the future" differ from the "hospital of today?"
"I think you will see much greater attention paid to internal communications," predicts Herbert Pardes, MD, president and CEO, New York Presbyterian Hospital and New York Presbyterian Healthcare System and the roundtable chair. "The notion of the isolated 'star' health provider is going to be modified, with a call for much more collaboration, teamwork, and attention to handoffs."
With the realization that communication is critical, he says, "I think you will see pressure to try to exploit — in the best sense of the word — IT to find various ways by which we can help people." He cites as an example a partnership his system entered with Microsoft to create the HealthVault, "so people can call up their health care information no matter where they are."
Much greater attention to safety issues also will be critical, Pardes continues."I think all hospitals will try to figure out how to be as efficient as possible, and to reach out to their community as much as possible," he says. "And in new hospital construction, we will see a bigger move toward single rooms."
This is an issue both of patient safety and patient-centered care, Pardes explains. "The notion of trying to make the hospital more person-centric will prevail," he says. "And even though some may say it will be more expensive to only have single rooms, I feel that the resulting drop in infection will trump that."
Other related issues, he says, include increased valuing of the centrality of the nurse and increased use of hospitalists (which we are already seeing). "I foresee a continued push on [reducing] length of stay," he adds. "Putting it all together, we're looking at care that is more centered on the comfort of the patient, an emphasis on both patient and staff satisfaction, as much improvement of quality and safety as possible, pressure for more systematic communication with each other, and playing a role in making the general health in our own local area better. It's moved a bit that way, but it will do so more profoundly going forward. We'll also see more attention to 'green' hospitals — energy conservation and using materials in a way that is environmentally sensitive."
Breaking new ground?
One or more of these core areas will represent terra incognita for some quality managers — for example, hospital design. Terri Tye, director of public affairs for The Joint Commission and primary author of the white paper, emphasizes the quality impact, for example, of the single room.
"Single rooms are being widely embraced in the hospital industry and I believe are part of the new AIA [American Institute of Architecture] guidelines for hospital design," says Tye. "Obviously, if you don't have two patients close together, you will reduce infection, but when doctors and nurses enter the room and go from one bed to another, there's also a great opportunity to spread microbes. Then there's the issue of the same ventilation system being shared by two patients."
Hospital-acquired infections, Tye points out, add significantly to health system costs. "And there's so much evidence to support single rooms — not just for safety but for outcomes," she says.
Another important design consideration, Tye continues, involves noise-reducing materials. "Obviously, with a lot of noise it's hard to get a good night's rest, so noise can be fatiguing for patients and for the health care staff," says Tye, who recommends a visit to the web site of the Center for Health Design (http://www.healthdesign.org) for more information.
The white paper also espouses using process improvement tools "to increase efficiency and reduce costs." While organizations such as the the Institute for Healthcare Improvement have been promoting improved efficiency as quality value, it has certainly not achieved universal adoption among hospitals.
"When there is waste or there are inefficient processes there are often greater opportunities for safety to be compromised," Tye asserts. "If you have 10 steps in a care process where three are really optimal, the seven steps you don't need create seven more opportunities to make an error."
The "tools" to which the white paper refers include some that are familiar to many quality managers, such as Lean and Six Sigma. "Everyone in health care is interested [in efficiency] now that costs are so high and the country is in such a dire economic condition, and it's even more important to drive out waste," says Tye. Coordinated care, she adds, is another way of improving efficiency. "When care is not coordinated, it increases utilization and re-hospitalization," she asserts. "Take, for instance, caring for chronically ill patients — or any patient that has to go through hospitalization from admission to discharge. When care is not coordinated, it leads to errors and waste and inefficiency — for example, medications are prescribed but not reconciled."
Nursing significantly impacted
As indicated above, nurses will play an increasingly important role in the "hospital of the future." They also are facing some of the toughest challenges, notes Rita Munley Gallagher, PhD, RN, senior policy fellow, department of nursing practice and policy for the American Nurses Association, and a member of the roundtable.
"If you look at the guiding principles, a significant number of them were devoted to addressing the staffing challenge, and we're absolutely supportive of those guidelines," says Gallagher. "The first thing that our group addressed was the issue of broad distribution of workers around the world; it's almost a revolving door going from one country to another, and it's not exclusive to the U.S.; so in order for hospitals of the future to meet the needs of patients in the U.S., this global issue has to be addressed."
In addition, she says, "it's real clear we need to expand education and training opportunities here in the U.S."
Finally, notes Gallagher, "the workplace is not — in many instances — a particularly attractive place. We see people leaving in a very short period of time. We need to develop the people who will be providing care because the environment is becoming more and more complex."
One example of this complexity, she continues, is the aging population. "As we all begin to age, hospitals will have more and more gerontological patients, so the workforce really needs to have competence; there's a critical need for health care professionals to understand the differences in caring for this population."
Some of those differences may be fairly obvious, such as the need for fall prevention strategies, while others, Gallagher says, may not. "For example, medications work differently in many instances, and that is a clear risk management issue," she notes. "There is a need to ensure that meds being prescribed and administered are in the first place appropriate and that the dosage is correct."
Sometimes, she explains, medications need to be titrated in different doses for elderly patients because their metabolisms are different — and this may vary from patient to patient. "In some respects, this is a very individualized approach," she says. "It's not cut and dried; you need to be vigilant as you provide care to be sure the medications are working as they are supposed to, and then if you identify some different responses, you need to ensure they receive different doses; it's a matter of vigilance and monitoring."
[For more information, contact:
Rita Munley Gallagher, PhD, RN, Senior Policy Fellow, Department of Nursing Practice and Policy, American Nurses Association, 8515 Georgia Avenue, Suite 400, Silver Spring, MD 20910-3492, Phone: (301) 628-5062, Fax: (240) 363-4919, E-mail: Rita.Gallagher@ANA.org;
Herbert Pardes, MD, President and CEO, New York Presbyterian Hospital, New York Presbyterian Healthcare System, New York, NY, Phone: (212) 305-8000;
Terri Tye, Director of Public Affairs, The Joint Commission, One Renaissance Boulevard, Oakbrook Terrace, IL 60181, Phone: (630) 792-5000.]