Health care redesign: managing a changing health care environment

Abstract

Introduction: Hospitals are changing from functional and bureaucratic organizations towards process-oriented service-line organizations [1,2]. At the same time, management techniques originating from industrial practices are diffusing throughout hospitals [3-5]. This results in the awareness that there should be a better fit between the customer needs and the service delivery processes in the future design of hospital care, which requires a rethinking of the business models used by hospitals. Moreover, to date, the majority of hospitals use one business model to treat patients with very different needs. Understandably, This ‘one-size-fits-all’ model has been criticized and more ‘focused’ delivery systems have been proposed [6,7]. Some authors make the distinction between ‘solution shops’, focusing on patients with a high degree of uncertainty in the care delivery such as in the diagnostic stage, ‘value adding process business’ (VAP), focusing on the efficient and safe treatment of patient paths with a limited amount of uncertainty, and ‘facilitated networks’ focusing on integrated care for chronically ill patients [6](see figure). In summary, uncertainty, as reflected in the amount of variability in the patient delivery path, seems to be an important variable of how to design a hospital delivery system which is more focused to the needs of groups of patients [7]. In this study we want to analyze whether structured and unstructured care can be recognized in the care for a patient population of acute care hospitals when looking at the length-of-stay(LOS) variability in the All Patient Refined Diagnosis Related Groups(APR-DRG), and therefore observe if individual departments already apply a differentiated approach to patient care. Methods: Data were collected in two large Belgian hospitals from March 2009 until April 2011. All Patient Refined Diagnosis Related Groups (APR-DRG) were used for analyses. These data were linked with demographic data (gender, age), administrative data (date of admission, date of discharge, re-admission) and APR-DRG specific data (Medical Diagnostic Categories (MDC), surgery or medicine, charged number of admitted days, severity of illness and risk of mortality). Results: Our analyses show that the patient population of the two hospitals can, to some extent, be separated in different business models (solution shops, VAPs and facilitated networks) by looking at the variability of the length of stay (LOS) and the level of severity of illness within APR-DRG categories. It becomes also clear that both hospitals do take into account the amount of uncertainty and variability in the way they organize the care process (e.g. by using different care coordination mechanisms such as clinical pathways), but are not really designed around these differential patient needs. In other words structured and unstructured care are delivered in the same departments (the so-called ‘all-in-one’ concept) with the same people, but in a differential way . Discussion: Most hospitals still deliver care using a one-size-fits-all model, thereby denying that customers’ needs can be different. Our study shows that, although hospitals are still organized from the perspective of one single business model, individual departments already apply a differentiated approach to patient care. Solution shops, VAPs and facilitated networks are present in hospitals, albeit in an embryonic stage. This shows that health care workers acknowledge the need for a differentiated approach and the change that has to be made is not as radical as one could think. 1. Gemmel, P., D. Vandaele, and W. Tambeur. Hospital Process Orientation (HPO): The development of a measurement tool. Total Quality Management & Business Excellence, 2008; 19: 1207-17. 2. Vos, L., et al. Towards an organisation-wide process-oriented organisation of care: A literature review. Implementation Science, 2011; 6. 3. Mazzocato, P., et al. Lean thinking in health care: a realistic review of the literature. Qual Saf Health Care, 2010; 19: 376-82. 4. Jimmerson, C., D. Weber, and D.K. Sobek. Reducing Waste and Errors: Piloting Lean Principles at Intermountain Healthcare. Joint Commission Journal on Quality and Patient Safety, 2005; 31: 249-57. 5. Herzlinger, R.E. Market-driven health care + Response to Andrew Hacker. Cambridge-Massachusetts, Perseus Book, 1997. 6. Bohmer, R.M.J., Designing Care. Boston, Massachusetts: Harvard Business School press, 2009. 7. Christensen, C.M., J.H. Grossman, and J. Hwang (2009) The Innovator' Prescription A disruptive Solution for Health Care. New York, Mc Graw-Hill books, 2009