The role of the hospital in a changing environment Martin McKee1 & Judith Healy2
Hospitals pose many challenges to those undertaking reform of health care systems. This paper examines the evolving role of the hospital within the health care system in industrialized countries and explores the evidence on which policy- makers might base their decisions. It begins by tracing the evolving concept of the hospital, concluding that hospitals must continue to evolve in response to factors such as changing health care needs and emerging technologies. The size and distribution of hospitals are matters for ongoing debate. This paper concludes that evidence in favour of concentrating hospital facilities, whether as a means of enhancing effectiveness or efficiency, is less robust than is often assumed. Noting that care provided in hospitals is often less than satisfactory, this paper summarizes the evidence underlying three reform strategies: (i) behavioural interventions such as quality assurance programmes; (ii) changing organizational culture; and (iii) the use of financial incentives. Isolated behavioural interventions have a limited impact, but are more effective when combined. Financial incentives are blunt instruments that must be monitored. Organizational culture, which has previously received relatively little attention, appears to be an important determinant of quality of care and is threatened by ill-considered policies intended to ‘re-engineer’ hospital services. Overall, evidence on the effectiveness of policies relating to hospitals is limited and this paper indicates where such evidence can be found.
Keywords: hospitals; health facility environment; health care reform; organizational innovation; developed countries.
Voir page 808 le re´sume´ en franc¸ais. En la pa´ gina 809 figura un resumen en espan˜ ol.
Introduction of the medical professional and often leaves the outsider confused and perplexed. Hospitals pose many challenges to those undertaking Given these barriers to change, it is unsurpris- reform of health care systems. They are, quite ing that hospital reform is viewed with trepidation by literally, immovable structures whose design was set health policy-makers. Yet hospitals are a very in concrete, usually many years previously. Their important element of the health care system. configuration often reflects the practice of health care Financially, they account for about 50% of overall and the patient populations of a bygone era. Their health care expenditure. Organizationally, they incompatibility with present needs ranges from major dominate the rest of the health care system. design problems, such as a scarcity of operating Symbolically, they are viewed by the public as the theatres, to more minor problems, such as the lack of main manifestation of the health care system, as power sockets for the ever expanding number of shown by the enthusiasm with which politicians seek electronic monitors. to be photographed opening new hospitals. It is not only the physical structure that is This paper seeks to redress this information difficult to change. Hospital functions are also balance by examining the place of the hospital within resistant to change, as illustrated by the persistence the health care system in industrialized countries. It of large tuberculosis sanitoria in some countries long draws on a major study being undertaken by the after they were required. Hospitals are staffed by the European Observatory on Health Care Systems, e´lite members of the medical profession who, in which addresses a series of crucial but often many cases, can use their excellent political connec- overlooked questions. First, why were hospitals tions to oppose changes that threaten their interests. created and do these conditions still pertain? Has An environment that is technically complex, sur- the dramatic growth in knowledge and technology rounded by much uncertainty, and which contains invalidated the nineteenth-century foundations of information asymmetry, only enhances the mystique hospitals? More fundamentally, what do we mean by the term ‘hospital’ and does the designation of a building as a ‘hospital’ mean the same thing every- 1 Research Director and Professor of European Public Health, European where? Observatory on Health Care Systems, London School of Hygiene Second, if hospitals are to be integral parts of and Tropical Medicine, Keppel Street, London WC1E 7HT, the health care system, what should they look like? England. Correspondence should be addressed to this author (email:[email protected]). What size should they be? How should they be 2 Senior Research Fellow, European Observatory on Health Care distributed within a geographical area? What should Systems, London School of Hygiene and Tropical Medicine, England. they look like on the inside? How can hospitals be designed in ways that enhance their performance, Ref. No. 00-0665
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both in terms of health outcomes and economic diagnosis and the recognition of new, and often performance? treatable, diseases. The massive expansion in phar- Finally, hospitals are often considered as black maceuticals transformed the management of diseases boxes when, in reality, they are complex adaptive and conditions such as peptic ulcer, childhood human systems. Why do some hospitals seem to leukaemia and some solid cancers. New specialities work well whereas others do not? How can hospital emerged, such as oncology, and common conditions performance be optimized? These questions will be such as peptic ulcer, previously treated with considered in turn. prolonged hospitalization, were managed in ambula- tory care. Whole new areas of surgery became commonplace, such as coronary artery bypasses, Why hospitals? transplantation of kidneys and other organs, and microsurgery. Hospitals, as recognizable institutions, emerged at These advances took place against a back- different times in different places, reflecting existing ground of changing patterns of disease. At least in social and, especially, religious contexts. The first industrialized countries, many infectious diseases recorded hospitals arose in the Byzantine Empire in were disappearing. General surgeons saw fewer cases the fifth and sixth centuries AD (1). Hospitals in of acute appendicitis. Orthopaedic surgeons turned western Europe emerged later, beginning in the to hip replacements, as a substitute for surgery on monasteries (2), a legacy reflected in the religious tuberculous disease of the spine, or tendon trans- designations of many present-day European hospi- plants for poliomyelitis. Thoracic surgeons, no longer tals. Most health care relied on extended families and occupied by tuberculous lung cavities, turned to the local communities, however, since formal health surgical management of lung cancer and to open services had little to offer. heart surgery. The industrial revolution brought enormous By the beginning of the twenty-first century, social changes that impacted on health and health the work of a major hospital in an industrialized care. The rapid growth of cities provided opportu- country has been transformed from that of a century nities for transmission of infections, unsafe factories earlier. The image beamed into homes throughout increased injuries, death rates rose rapidly, and social the world, in television programmes such as the supports crumbled with increasing population mo- North American series ‘‘ER’’, is that a ‘hospital’ bility. A combination of philanthropy and self- means a modern complex in which seriously ill interest among the wealthy stimulated both public patients are treated at high speed with highly technical health measures and the construction of new equipment and by skilled specialist staff. A patient hospitals. However, urban overcrowding and high with a head injury is given an immediate magnetic levels of infection often meant that going into these resonance imaging scan and is seen by a neurosur- hospitals actually increased the chance of one dying. geon who has subspecialized in intracerebral trauma. By the end of the nineteenth century infectious By contrast, a small rural hospital in a middle- disease was beginning to be understood. Semmelweis income country, providing basic care with limited showed that hand-washing could reduce the trans- facilities, could not be more different. For this image mission of puerperal fever. Lister’s introduction of we can turn to the travel writer, Colin Thubron, who antisepsis, coupled with the discovery of safe describes a small hospital in Siberia thus: ‘‘Inside the anaesthetic agents, made elective surgery safer. In building was a simple range of three-bed wards, a England, Florence Nightingale established a profes- kitchen and a consulting room. It had no running sional basis for nursing. Hospitals were now able to water, and its lavatory was a hole in the ground. offer more than basic care, but their role as a setting Between the double windows the sealing moss had for medical treatment was not yet established, and the fallen in faded tresses. It was almost without middle classes continued to have the doctor treat equipment.’’ (3) them at home. By the twentieth century, the hospital While these two images represent the extremes was beginning to take on its present-day role. of the spectrum, there is considerable diversity even Advances in chemical engineering laid the basis for within relatively homogenous health care systems. a pharmaceutical industry; for example, research on Some hospitals provide high intensity care with chemical dyes led to the invention of sulfonamides. specialized back-up from a range of surgical Hospitals began to offer cure rather than care. As the specialities, while others concentrate on less acute scope for clinical intervention increased, technology care or even convalescence and rehabilitation. became more complex and expensive. By the 1930s, few surgeons operated on wealthy patients in their own houses. Competing roles? Advances in military surgery in the Second World War had a profound impact on hospital care, From this brief review it can be seen that the survival with the introduction of safe blood transfusion, of the hospital as an institution reflects two quite penicillin, and surgeons trained in trauma techniques. different needs. The first derives from the rapid The greatest changes occurred from the 1970s growth of advanced technology and clinical specia- onwards, however, with advances in laboratory lization. The resources involved, including humans
804 Bulletin of the World Health Organization, 2000, 78 (6) The role of the hospital in a changing environment and equipment, are scarce and expensive. It is simply charge policies or different levels of social support. not tenable to disperse such resources across a large More fundamentally, mortality as a measure of number of small facilities. This situation is analogous outcome, although relatively easily measured, is a to the growth of the factory in the eighteenth century, partial measure of quality of care, since it ignores non- driven by the spread of the steam engine, that made fatal complications and quality of life. There is also a the earlier cottage industries obsolete. risk that a narrow focus on outcomes may obscure The second need, to provide care rather than important differences in the process of care (5). cure, is quite different. Care requires people rather There are many other unresolved issues. For than equipment, and generalists rather than specia- example, research has tended to concentrate on lists. Centralization of services is not necessary on hospital rather than physician volume. If an associa- cost grounds, especially since access may be more tion between volume and outcome is demonstrable important for patients and families. at the level of the physician, could the benefits of In this complex environment it is essential that higher volumes be achieved by guidelines and clinical policy-makers know which aspects of hospital design protocols that diffuse good practice? and configuration are supported by evidence and Nonetheless, certain findings do emerge. The which are not. This paper seeks to offer an volume of procedures at which optimal results are introduction to some of the research upon which achieved is often relatively low. In the case of they can draw. coronary artery bypass grafting, there is no significant improvement in outcome in hospitals undertaking over 200 procedures per year. In most countries, few What should a hospital look like? hospitals undertake such a low volume of cases. Studies that have examined both hospital and The configuration of hospital services in a given physician volume have found a relationship between setting reflects a tension between two competing outcome and hospital volume, but not between objectives: centralization versus dispersion of hospi- outcome and physician volume (6–9), suggesting that tal services. There are two arguments for centralizing the collective expertise of the entire surgical team is hospital services. First, hospitals and clinicians more important than that of the individual surgeon. undertaking high volumes of work achieve better This finding is plausible given that surgical patients outcomes; and second, large hospitals achieve are more likely to die from post-operative complica- economies of scale. The counter argument for tions than from problems occurring in the operating dispersing hospitals is that this improves population theatre. access and reduces inequalities. These arguments are discussed in more detail below. Large hospitals achieve economies of scale The major source of evidence on these issues is The second argument for concentrating hospitals is a systematic review of over 200 studies undertaken in on grounds of efficiency, with larger hospitals 1996 by the Centre for Reviews and Dissemination at purportedly achieving economies of scale. This has the University of York (4). Although this review was been examined in detail by Aletras et al. (10), who extensive, it is important to remember that much of concluded that economies of scale, assuming the this research emanates from the USA and the United hospital is already operating at maximum efficiency, Kingdom, so that it is open to question as to whether are exploited at quite low levels of around 200 beds, the data are generally applicable. and diseconomies of scale become important at levels over 650 beds. The data were insufficient to specify Greater volume leads to better an optimal size but suggested it was in the range of health outcomes 200–400 beds. The authors of the University of York study Economies of scope should also be considered. concluded that the widely held view, that greater The hospital contains a complex set of interrelated volume led to better outcomes, was subject to several functions and one factor driving the growth of caveats. First, most authors overestimated the size of modern general hospitals was to gather different the relationship because it failed to take sufficient specialities together under one roof. There may be account of case mix. Second, if a causal association strong arguments for creating larger hospital units to does exist, the direction of causation cannot be facilitate links between related specialities, to established. In other words, does ‘‘practice make strengthen multidisciplinary teams, to ensure optimal perfect’’ or are better results in larger hospitals due to use of expensive equipment such as scanners or selective referral? Third, improvements in quality of operating theatres, or to support the training role of care could be achieved through greater specialization the hospital. Here, each case must be considered on within hospitals, rather than by increasing the size of its merits. the hospital. Although existing research on hospital configu- The authors also criticized the use of mortality rations has limitations, it provides little support for as a measure of outcome, especially since in-patient concentrating care in very large hospitals, either on deaths or 30-day mortality rates are not good grounds of effectiveness or efficiency, but some indicators of long-term survival. Differences in concentration may be required to achieve economies short-term survival may also reflect different dis-
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of scope, which should then be made explicit. meet the needs of the population served must be Importantly, where the current pattern of provision decided; and it must then be decided how each is dispersed, there is little evidence to support function can best establish a critical mass for mergers of existing facilities. Ferguson & Goddard providing good quality care. It must be recognized (11) concluded that there was no conclusive evidence that in many places this has not yet been achieved, that hospital mergers undertaken to concentrate with multiple small units isolated from other facilities reduced total costs. First, management costs specialities and with duplication of costly equipment. may be reduced only in the short run; and second, In such cases, major restructuring will be required. important diseconomies may emerge due to the Once an integrated, effective and efficient system has difficulty of integrating staff and systems. Only where been established there is no strong case for there is clearly identified excess capacity that can be concentration into ever larger units, in pursuit of removed will concentration or merger be expected to economies of scale or better outcomes. reduce overall costs. Such a policy should, however, take account of other potential costs to the communities in which hospitals are situated, as the Unpacking the black box impact on total employment may be considerably greater than the number of jobs lost directly from Hospitals have been subjected to systematic efforts reorganizing the hospital (12). to change organizational behaviour over the last few An important argument against concentration decades. Three main approaches have been used to of hospitals is that such a policy will reduce access to improve performance: (i) providing incentives for care. This may be especially important if, as has been optimizing clinical performance; (ii) changing the suggested in New Zealand, differential access to organizational environment; and (iii) changing pay- health care contributes to socioeconomic inequalities ment mechanisms. in health (13). Such problems are likely to be greatest in rural areas, as illustrated by a study from France. Incentives for optimizing Patients with colorectal cancer living in rural areas clinical performance experienced greater delay in obtaining treatment, In many countries there is growing evidence that were less likely to be treated in specialist centres, and clinical performance in hospitals is sub-optimal. The also had worse outcomes than those in urban areas strategies used to address this problem include (14). The relationship between distance and access, quality assurance models, clinical audit and the new often characterized as a distance–decay effect, has concept of clinical governance, in which quality is a been reported for preventive, primary and secondary shared managerial and clinical responsibility. These care (15, 16). For example, in a study of factors are based on the assumption that quality assurance influencing uptake of breast cancer screening, activities and continuing professional development distance was the single most important factor (17). lead to improved quality of care. In a study from Northern Ireland, use of emergency Unfortunately, the available evidence, mostly services was much greater among those living closer drawn together within the framework of the Cochrane to a hospital (18). Furthermore, patients already Collaboration, demonstrates that clinical behaviour is attending hospital may be less likely to remain in a quite resistant to change. For example, a review of treatment programme if they must travel long 99 trials concluded that there was little or no change distances (19). following conferences or short educational events In contrast, several studies have found no (22). Freemantle similarly found no benefit from effect of distance on utilization of care (20, 21). The distribution of educational materials (23). Educational apparently conflicting evidence has been examined in outreach visits do, however, make a small impact on detail by Carr-Hill et al. (22), who noted that the behaviour (24) and the classical audit and feedback research is subject to several limitations. One is the model works in some circumstances (25). Perhaps the need for caution when extrapolating from a country most important finding to emerge is that behavioural such as the United Kingdom, where the distances change is most likely to follow a range of interventions involved are generally short, to a country like Canada that are mutually reinforcing (26). where distances may be vastly greater. Another is the absence, in many studies, of an examination of any Changing the organizational environment differential impact of distance upon different social A second approach to improving the quality of care classes or ethnic groups. The absence of an overall has emerged from research on the relationship effect, therefore, may obscure important inequalities between organizational culture and quality of care within particular population groups. (27). Certain hospitals (‘‘magnet’’ hospitals) were In summary, access is generally more impor- identified that were widely regarded by nurses as tant in relation to primary care, outpatient services, offering a good environment in which to practise and screening programmes, with inpatient care being nursing (but where patient outcomes were un- relatively less affected. These findings have impor- known). These hospitals were characterized by tant implications for hospital planning, since they greater nursing autonomy and better relationships show that hospital size is only one consideration. For between doctors and nurses. These hospitals were example, the overall mix of functions required to
806 Bulletin of the World Health Organization, 2000, 78 (6) The role of the hospital in a changing environment matched with controls and, after adjustment for times, is especially risky in this situation. As discussed severity, the ‘‘magnet’’ hospitals achieved a signifi- earlier, the environment in which hospitals exist has cantly lower inpatient mortality rate. continually changed and the pace of change is Other work reached similar conclusions, find- accelerating. The situation is complicated further in ing tangible benefits to patients from a supportive that different countries start from very different culture among clinical staff (28). For example, baselines and face different challenges, both in the organizational and professional job satisfaction demands placed upon them and the resources among nurses is a strong predictor of process available to them. measures of quality of care (29). In intensive care It is, however, possible to speculate about units, the best predictors of better patient outcomes some factors. A key issue will be the continually are organizational factors such as a patient-centred changing burden of disease, although the effects are culture, strong medical and nursing leadership, difficult to quantify. First, the nature of the change effective collaboration, and an open approach to will be different in every country, reflecting differ- problem solving (30). ences in, for example, diet, smoking rates and This research has several important implica- exposure to risk of injury or infections. Second, it is tions. First, it helps us understand why some possible that some previously unknown disease will hospitals perform better than others. Second, it emerge, as human immunodeficiency virus (HIV)/ highlights the fact that hospitals are complex human acquired immunodeficiency syndrome (AIDS) service organizations, and not just assemblies of emerged in the twentieth century. Changes in industrial units to be reconfigured at will. Major patterns of existing diseases are more amenable to organizational change can have profound implica- prediction, at least in the short term. In many tions for a hospital workforce and, while a hospital industrialized countries, for example, rates of some must adapt to a changing environment, radical chronic diseases will continue to fall. However, this restructuring may adversely affect the quality of will be accompanied by increases in degenerative patient care if it damages staff morale and a collegial disorders such as Alzheimer disease, increasing the ethos. need for care rather than cure. Rapid increases in smoking-related diseases can be predicted, as well as a continuing growth in AIDS. Changing payment mechanisms The possible consequences of newly emerging The third main approach to quality of care is the use diseases are much more problematic, with important of financial incentives. Payment mechanisms have consequences for clinical practice and hospital received considerable attention, but can only be design. An example has been the need to adopt mentioned briefly here. The ideal mechanism would universal precautions to prevent transmission of be one that offered incentives for producing HIV. In the future, the growth of antibiotic resistance effective, efficient and equitable treatment, with no may lead to further changes as diseases that are perverse incentives and with minimal transaction generally amenable to treatment, such as tubercu- costs. In practice, many of the systems fail on one or losis, become not only effectively incurable but also more of these counts (31). A perfect system is not of easily transmissible to staff and other patients. A course achievable, since there are inevitable trade- particular concern in some European countries is the offs. Financial incentives, while good at pushing possibility that human forms of bovine spongiform behaviour in a certain direction, are less good at encephalopathy (so-called mad cow disease) could putting limits upon financial motivation. In each case become widespread as the prion agent involved is it is important to identify, on the basis of empirical extremely resistant to sterilization (32). These drug- evidence, the positive and negative effects of each resistant and highly infectious diseases could funda- model of payment and then to monitor the effects in mentally challenge the concept of the hospital, practice. rendering them as dangerous as they were in the pre-antibiotic days. A second set of issues relates to changes in the Looking ahead people who work in hospitals. Some changes will reflect demographic trends and macroeconomic The health policy-maker is often faced with inherited trends, in particular affecting the size of the nursing hospitals that are the wrong size and shape and in the workforce. Others will reflect changing expectations, wrong place. The evidence reviewed above helps in suchasthewillingness toworklongandunsocialhours. deciding what a hospital should look like now, but Here, the need to provide 24-hour medical cover while hospitals cannot be built or converted instantly. A not degrading skills is, in some countries, acting as a decision to build a major hospital now means, in powerful force for concentrating facilities (33). optimal circumstances, that it will open in five years’ A third set of issues arises from developments time, with an expected operating life of around 50 in technology, with new possibilities for investigation years. The key challenge is thus to know what the or treatment. Examples include the continuing hospital of the future should look like. Will we still advances in imaging, fibre-optics and information need the hospital or can its functions be performed technology. These advances will lead to changes in elsewhere? Prediction, an imprecise art at the best of professional demarcations as particular tasks cease to
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be seen as the reserve of a single group. These treated in local ambulatory care centres, drawing on changes will affect not only the internal organization specialist expertise located remotely where necessary. of the hospital, but also its interface with the outside Conversely, it is arguable that this model ignores world, as complex diagnosis and treatment, and thus other roles of the hospital, in particular its caring role, patients, move into clinics for day surgery and into as well as its role in training and professional the primary care sector. development. Technology will also bring profound changes The hospital of the future must respond to all in what it is possible to do within the hospital. Early of these challenges. It must balance economies of computers occupied entire buildings, yet their scope with optimal access, drawing on advances in processing power was less than a present-day hand- technology as appropriate. It may need fewer beds, held organizer. The growth in information technol- but it will need more operating theatres and recovery ogy has left few areas of health care untouched, areas, as well as purpose-built facilities that can offer ranging from rapid processing of digital images to an one-day surgery, or integrated care for common enhanced capacity to monitor and more actively disorders (34). Most importantly, the hospital will manage patient care. Miniaturization has allowed need to be flexible, because the diseases it treats and user-friendly diagnostic kits to replace what would the ways in which it treats them will be very different previously have required a complex laboratory. As from those of today. n has already happened with AIDS in many countries, and with peptic ulcers previously, new drugs will Acknowledgements reduce demand for inpatient treatment. This paper draws on working papers prepared by What are the implications of these likely Linda Aiken, Nick Freemantle, John Posnett and changes for the hospital of the future? If a narrow Nigel Edwards. The European Observatory on technological perspective is taken, it is possible to Health Care Systems is a partnership between the argue that the hospital as a concept will no longer be London School of Hygiene and Tropical Medicine, justified. Advances in technology may mean that the the London School of Economics, the World Health hospital is not needed as a means of concentrating Organization, the World Bank, the European expensive equipment. Developments in communi- Investment Bank, and the governments of Norway cations technology and, in particular, telemedicine and Spain, with the Open Society Institute in may mean that the hospital is not needed to associate membership. However, the views ex- concentrate skilled staff. In such circumstances it is pressed are those of the authors alone and cannot conceivable that a virtual hospital could be con- be taken as representing those of any of the partner structed, in which patients would be diagnosed and organizations.
Re´ sume´ Le roˆ le de l’hoˆ pital dans un environnement en mutation Les hoˆ pitaux posent de nombreux proble`mes a` ceux qui dans beaucoup de pays, la tendance a e´te´ de fermer les entreprennent de re´former les syste`mes de soins de petits hoˆ pitaux et de concentrer les installations sur sante´. Cet article examine l’e´volution de la fonction de certains sites, les arguments cite´s en faveur de cette l’hoˆ pital dans le syste`me des soins de sante´ des pays politique sont moins solides qu’on ne le pense souvent, industrialise´s et analyse les e´le´ ments sur lesquels les que ce soit pour renforcer l’efficacite´ ou la rentabilite´. de´cideurs pourraient baser leurs de´cisions. Il commence Toutefois, les fermetures et les fusions peuvent eˆtre par retracer l’e´volution historique de l’hoˆ pital qui, de lieu justifie´es lorsqu’elles sont destine´esa`re´duire un exce`sde dans lequel les gens malades pouvaient se faire soigner, moyens ou a`re´aliser des e´conomies de gamme (c’est-a`- est devenu un e´tablissement hautement technique de dire lorsqu’on peut gagner en efficacite´ en rassemblant diagnostic et de traitement. Il analyse la fac¸on dont les diffe´rentes fonctions en un seul endroit). hoˆ pitaux ont continuellement e´ volue´enre´ponse a` des Prenant acte de ce que les soins fournis dans les facteurs externes, dont les plus importants ont e´te´ hoˆ pitaux sont souvent moins que satisfaisants, les l’e´mergence et le de´clin de diffe´ rentes maladies et des auteurs re´ capitulent les e´le´ments sous-jacents a` trois techniques dont on disposait pour y faire face. Toutefois, strate´gies de re´forme : interventions de type comporte- l’hoˆ pital n’est pas seulement une structure dans laquelle mental, par exemple programmes d’assurance de la appliquer des techniques de plus en plus sophistique´es qualite´ ; changement de la culture organisationnelle ; et en re´ ponse a` la maladie. C’est e´ galement un e´tablisse- recours a` des mesures d’incitation financie`re. Les ment de soins et de formation, et il appartient aux interventions comportementales, si elles sont isole´es, de´cideurs de trouver les moyens pour qu’il assume ces ont un impact limite´, mais elles sont plus efficaces diffe´rents roˆ les qui entrent parfois en compe´tition. lorsqu’elles sont associe´es a` un ensemble de mesures L’article se poursuit par un examen des arguments cohe´rentes. Les mesures d’incitation financie`re sont des avance´s concernant la configuration optimale des instruments dangereux qu’il faut surveiller a` cause du hoˆ pitaux. La taille et la re´partition des hoˆ pitaux sont risque d’effets pervers. La culture organisationnelle, qui des questions qui font l’objet d’un de´bat permanent. Si, n’a que peu retenu l’attention jusqu’ici, semble eˆ tre un
808 Bulletin of the World Health Organization, 2000, 78 (6) The role of the hospital in a changing environment de´terminant important de la qualite´ des soins, mais elle les changements s’ope`rent en fonction des nouvelles est menace´e par les politiques mal inspire´es visant a` possibilite´ s de traiter les patients en ambulatoire, mais «re´organiser » les services hospitaliers. aussi de celles que l’on aura de traiter a` l’hoˆ pital des Concernant l’avenir, les hoˆ pitaux sont continuel- malades actuellement incurables. En ne mettant l’accent lement confronte´s a` des changements, tant sur le plan que sur les progre`s technologiques, on risque de des maladies qu’ils traitent que sur celui du personnel conside´rer que l’hoˆ pital va devenir une notion de´passe´e, qu’ils emploient ou des techniques dont ils disposent. les progre`s scientifiques rendant inutile le fait que Ces changements auront des conse´quences nombreuses l’hoˆ pital rassemble du mate´riel couˆ teux et la te´le´me´ de- et varie´es, souvent contradictoires, dont certaines sont cine rendant inutile l’obligation d’avoir un personnel pre´visibles mais dont beaucoup ne le sont pas. qualifie´ en un endroit donne´. Toutefois, un tel mode`le Concernant les maladies, le changement porte sur ignore les autres fonctions de l’hoˆ pital, en particulier les l’e´volution des tendances existantes, mais aussi sur soins qu’on y prodigue, et son roˆ le dans la formation et l’e´mergence possible de nouvelles infections hautement dans la formation professionnelle continue. Le message contagieuses. Les modifications ope´re´ es dans la dotation peut-eˆtre le plus important pour l’avenir est de bien en personnel des hoˆ pitaux sont les conse´ quences de souligner l’importance de concevoir les hoˆ pitaux comme l’e´volution e´conomique et de´mographique, d’attentes devant eˆtre souples et devant conserver une certaine diffe´rentes et de l’apparition de fonctions et groupe- capacite´ d’adaptation au changement. ments professionnels nouveaux. Sur le plan technique,
Resumen Papel del hospital en un entorno en transformacio´n Los hospitales plantean muchos desafı´os para quienes comportamentales, como los programas de garantı´a de emprenden reformas de los sistemas de atencio´n de la calidad; la transformacio´ n del clima institucional; y el salud. En este artı´culo se describe la evolucio´ n del papel uso de incentivos financieros. Las intervenciones desempen˜ ado por los hospitales en el sistema asistencial comportamentales aisladas tienen una repercusio´n de los paı´ses industrializados y se examinan las pruebas limitada, pero son ma´ s eficaces cuando se combinan cientı´ficas sobre las que los formuladores de polı´ticas en un paquete coherente de medidas. Los incentivos podrı´an basar sus decisiones. Al principio se analiza la financieros son instrumentos burdos que deben ser transformacio´ n que han sufrido los hospitales, que de ser objeto de vigilancia pues pueden tener efectos perversos. un lugar donde se atendı´a a los enfermos han pasado a El clima institucional, relativamente ignorado hasta ser un entorno altamente te´cnico de diagno´ stico y ahora, parece ser un importante determinante de la tratamiento. Se muestra co´ mo los hospitales han calidad de la asistencia, pero se ve amenazado por evolucionado continuamente en respuesta a factores polı´ticas poco meditadas encaminadas a reestructurar externos, los ma´ s importantes de los cuales son el radicalmente los servicios hospitalarios. aumento o disminucio´ n de distintas enfermedades y las Mirando hacia el futuro, los hospitales han de oportunidades te´cnicas disponibles para responder a hacer frente a la continua transformacio´n de las ellas. Sin embargo, el hospital no es so´ lo una estructura enfermedades que tratan, del personal que trabaja en en la que pueden emplearse tecnologı´as cada vez ma´s ellos y de la tecnologı´a a su disposicio´ n. Todos esos sofisticadas contra las enfermedades, es tambie´n un factores tendra´ n muchas implicaciones diferentes, y a entorno de prestacio´ n de cuidados y de capacitacio´n,e menudo incompatibles, predecibles algunas, pero no ası´ incumbe a los formuladores de polı´ticas hallar la manera muchas otras. Los cambios que experimenten las de combinar esas funciones a veces ren˜ idas. enfermedades sera´ n en parte el resultado de tendencias A continuacio´ n se analizan los argumentos actuales, pero hay que prever tambie´ n la posible esgrimidos respecto a la configuracio´n o´ ptima de los emergencia de nuevas infecciones altamente contagio- hospitales. Se sigue discutiendo cua´ l debe ser su taman˜o sas. Los cambios que afectara´ n al personal hospitalario y distribucio´ n. Aunque en muchos paı´ses ha habido se debera´ n a factores econo´ micos y demogra´ ficos, a las iniciativas para cerrar los hospitales ma´ s pequen˜os y diferentes expectativas creadas y a la aparicio´n de centrar los servicios en un solo sitio, los datos citados a nuevas funciones y asociaciones profesionales y labora- favor de esta polı´tica, en lo que atan˜ e a mejorar tanto la les. Entre los cambios tecnolo´ gicos figurara´ la posibilidad eficacia como la eficiencia, son menos so´ lidos de lo que a de tratar a los pacientes fuera del hospital, pero tambie´n menudo se supone. No obstante, los cierres y fusiones la de tratar en el hospital casos actualmente intratables. pueden estar justificados cuando se trata de reducir un Una perspectiva basada exclusivamente en los avances exceso de capacidad o de lograr economı´as de alcance tecnolo´ gicos podrı´a llevar a pensar que el concepto de (esto es, cuando se puede conseguir una mayor eficiencia hospital perdera´ vigencia, pues los avances cientı´ficos concentrando diferentes funciones en un solo lugar). evitara´ n la necesidad de concentrar equipo oneroso en Tras sen˜ alar que la atencio´ n proporcionada en los hospitales, y la telemedicina hara´ innecesaria la hospitales dista con frecuencia de ser satisfactoria, el concentracio´ n del personal especializado en un solo artı´culo resume las pruebas cientı´ficas que fundamentan lugar. Sin embargo, ese enfoque ignora las otras tres estrategias de reforma; a saber, las intervenciones funciones del hospital, en particular su papel asistencial,
Bulletin of the World Health Organization, 2000, 78 (6) 809 Special Theme – Health Systems
ası´como su contribucio´ n a la capacitacio´ n y al desarrollo hospitales se disen˜ en de manera que sean flexibles y profesional permanente. El mensaje ma´ s importante conserven la capacidad de adaptarse a las transforma- para el futuro es tal vez la necesidad de asegurar que los ciones del entorno.
References 1. Miller TS. The birth of the hospital in the Byzantine Empire. 21. Kohli HS et al. How accessible is the breast screening assessment Baltimore, Johns Hopkins University Press, 1997. centre for Lanarkshire women? Health Bulletin, 1995, 2. Porter R. The greatest benefit to mankind: a medical history of 53: 153–158. humanity from antiquity to the present. London, Harper Collins 22. Carr-Hill RA, Place M, Posnett J. Access and the utilization Publishers, 1997. of healthcare services. In: Ferguson B, Sheldon T, Posnett J, eds. 3. Thubron C. In Siberia. London, Chatto & Windus, 1999. Concentration and choice in health care. Glasgow, Royal Society of 4. Hospital volume and health care outcomes, costs and patient Medicine Press, 1997: 37–49. access. York, National Health Service Centre for Reviews and 23. Freemantle N et al. Printed educational materials: effects Dissemination, University of York, 1996. on professional practice and health care outcomes (Cochrane 5. Mant J, Hicks N. Detecting differences in quality of care: Review). In: The Cochrane Library, Issue 2, 2000. Oxford, Update sensitivity of measures of process and outcome in treating Software (electronic document; abstract available on the Internet acute myocardial infarction. British Medical Journal, 1995, at http://www.update-software.com/ccweb/cochrane/revabstr/ 311: 793–796. ab000172.htm). 6. Kelly JV, Hellinger FJ. Physician and hospital factors associated 24. Thomson O’Brien MA et al. Local opinion leaders: effects on with mortality of surgical patients. Medical Care, 1986, professional practice and health care outcomes (Cochrane 24: 785–800. Review). In: The Cochrane Library, Issue 2, 2000. Oxford, Update 7. Flood AB, Scott WR, Ewy W. Does practice make perfect? Part I: Software (electronic document; abstract available on the Internet The relation between hospital volume and outcomes for selected at http://www.update-software.com/ccweb/cochrane/revabstr/ diagnostic categories. Medical Care, 1984, 22: 98–114. ab000125.htm). 8. Kelly JV, Hellinger FJ. Heart disease and hospital deaths: an 25. Thomson O’Brien MA et al. Audit and feedback to improve empirical study. Health Services Research, 1987, 22: 369–395. health professional practice and health care outcomes (Cochrane 9. Hannan EL et al. Investigation of the relationship between Review). In: The Cochrane Library, Issue 2, 2000. Oxford, Update volume and mortality for surgical procedures performed in New Software. York State hospitals. Journal of the American Medical Association, 26. Davis DA et al. Changing physician performance. A systematic 1989, 262: 503–510. review of the effect of continuing medical education strategies. 10. Aletras V, Jones A, Sheldon TA. Economies of scale and scope. Journal of the American Medical Association, 1995, In: Ferguson B, Sheldon T, Posnett J, eds. Concentration and 274: 700–705. choice in health care. Glasgow, Royal Society of Medicine Press, 27. Aiken LH, Smith HL, Lake ET. Lower Medicare mortality among 1997: 23–36. a set of hospitals known for good nursing care. Medical Care, 11. Ferguson B, Goodard M. The case for and against mergers. 1994, 32: 771–787. In: Ferguson B, Sheldon T, Posnett J, eds. Concentration and 28. Shortell SM et al. Assessing the impact of continuous quality choice in health care. Glasgow, Royal Society of Medicine Press, improvement/total quality management: concept versus imple- 1997: 67–82. mentation. Health Services Research, 1995, 30: 377–401. 12. Cordes S et al. Rural hospitals and the local economy: a needed 29. Leveck ML, Jones CB. The nursing practice environment, staff extension and refinement of existing empirical research. Journal of retention, and quality of care. Research in Nursing Health, 1996, Rural Health, 1999, 15: 189–201. 19: 331–343. 13. Marshall SW et al. Social class differences in mortality from 30. Zimmerman JE et al. Improving intensive care: observations diseases amenable to medical intervention in New Zealand. based on organisational case studies in nine intensive care units: a International Journal of Epidemiology, 1993, 22: 255–261. prospective, multicenter study. Critical Care Medicine, 1993, 14. Launoy G et al. Influence of rural environment on diagnosis, 21: 1443–1451. treatment and prognosis of colorectal cancer. Journal of 31. Wiley M. Finance operating costs for acute hospitals. In: Epidemiology and Community Health, 1992, 46: 365–367. Saltman RB, Figueras J, Sakellarides C, eds. Critical challenges 15. Hayes RM, Bentham CG. Community hospitals and rural for health care reform in Europe. Buckingham, Open University accessibility. Farnborough, Saxon House, 1979. Press, 1998: 218–235. 16. Ritchie J, Jacoby A, Bone M. Access to primary health care. 32. Ghani AC et al. Epidemiological determinants of the pattern London, Her Majesty’s Stationery Office, 1981. and magnitude of the vCJD epidemic in Great Britain. Proceedings 17. Haiart D et al. Mobile breast screening factors affecting uptake, of the Royal Society of London. Series B: Biological Sciences, 1998, efforts to increase response and acceptability. Public Health, 265: 2443–2452. 1990, 104: 239–247. 33. McKee CM, Black N. Hours of work of junior hospital doctors: 18. McKee CM, Gleadhill DN, Watson JD. Accident and is there a solution? Journal of Management Medicine, 1991, emergency attendance rates: variation among patients from 5: 40–54. different general practices. British Journal of General Practice, 34. Waghorn A, McKee M, Thompson J. Surgical outpatients: 1990, 40: 150–153. challenges and responses. British Journal of Surgery, 1997, 19. Fortney JC et al. The effects of travel barriers and age on the 84: 300–307. utilization of alcoholism treatment aftercare. American Journal of Drug and Alcohol Abuse, 1995, 21: 391–406. 20. Junor EJ, MacBeth FR, Barrett A. An audit of travel and waiting times for out-patient radiotherapy. Clinical Oncology, 1992, 4: 174–176.
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