While most of the focus has been on D.C. and the trillions of dollars to be spent on healthcare reform, HM has grown substantially in the last decade without any significant payment reform or new regulation. This is all the more incredible because the rise of HM has involved two institutions not synonymous with accepting or adapting to change: physicians and hospitals.
In the coming years, hospitals face important challenges, including their fiscal survival, public trust, workforce shortages, difficulty deciding whether their physicians are partners or competitors, and figuring out what to do about all this patient safety and performance improvement hubbub.
Although 2010’s version of healthcare reform will be about increasing access (see “An Imperfect Solution,” January 2010, p. 44), there are still the seeds planted to address the next two pillars of reform: reducing cost and rewarding performance. Together, they create the value proposition in healthcare. All this will make the coming decade one in which the hospital as an institution will need to evolve and adapt if it is to survive.
What is Quality?
As we enter a transitional phase, in some ways, we aren’t even clear on just what quality healthcare is:
- Is quality defined as a payment issue? We see this in discussions of not paying for “never events” or denying payment for readmissions.
- Is quality about being more satisfied? This is found in emphasis on the surveys of patient and family satisfaction that drive hospital CEO compensation and bonuses, as well as in efforts to improve staff retention or in recognition by business, insurers, and government.
- Is quality just checking things off on a clipboard? We all see the endless list of quality measures and increasing documentation that providers have told their patients to stop smoking or get a flu shot, but is that really the quality we are seeking in healthcare?
- Is quality just avoiding embarrassment? Is the best driver of performance improvement outraged hospital trustees wielding printouts comparing hospitals?
We do know that in some ways, the discussion at most of our hospitals has shifted from “Is quality important?” to “How do we do it?” And in this discussion, HM and SHM have taken a leading role in the “solutions” to the problem. Our innovative programs help reduce unnecessary DVTs, improve glycemic control, and refine the discharge process (see Project BOOST) for better patient/family satisfaction, reduced ED visits, and reduced readmissions.
New Ways to Deliver Care
The hospital of the future—I’m talking 2020—will not be defined by bricks and walls. The hospital stay will not end with a patient in a wheelchair being helped into their car. We already know that most patients don’t leave the hospital cured, but are discharged when they are not sick enough to need to stay recumbent in the most expensive hotel in the city. Often these patients are in midcourse of an acute illness, frequently imposed on top of chronic dysfunctions.
While the patient as the true “medical home” for their health and illness have always borne the potholes of slipped handoffs and information transfer deficits, hospitalists now have a clear view of the precarious nature of post-discharge care. Bundling and payment reform, designed to reward coordination of care and the reduction of readmissions to the ED, might be a revenue-driven boost to our ill-designed healthcare system, but the hospital, with the help of their hospitalists, can take the lead in fixing these problems. And we don’t have to wait for payment reform.