Reversing Hyper-specialization In the Hospital

Tom Peters

For every dollar hospitals spend on direct care, calculates Booz-Allen & Hamilton consultant J. Philip Lathrop, they spend another $3 to $4 “waiting for it to happen, arranging to do it, and writing it down.” In the July/August issue of Healthcare Forum Journal, Lathrop provides a disturbing analysis of current hospital-service delivery—and a stunning solution, which he and his colleagues call “the patient-focused hospital.”

First, the indictment. “We have convinced ourselves and patients,” Lathrop writes, “that a one- or two-hour odyssey for a routine X-ray exam is ‘good service.'” One effect of nonsense like this: Clerks and secretaries alone outnumber patients in most hospitals. The genesis of such problems is, above all, hyper-specialization. At Indianapolis’s 1041-bed St. Vincent Hospital, for example, there are 598 separate job classifications; 362 have only a single incumbent. Lathrop concludes that patients receive good treatment, but “pay a terrible price in terms of confusion, lack of continuity, impersonal care, and (excessive) cost.”

The patient-focused model Lathrop advocates is based on three years of research. It takes dead aim at the centralization of routine activities, which constitute most of the services provided to a typical patient. The new approach features largely self-contained service-delivery units:

– “Caregivers are cross-trained to provide 80 to 90 percent of the services their patients need—including traditional bedside nursing, basic X-ray films, routine lab work, respiratory care, and EKGs. Appropriate … equipment is redeployed to the unit. As a result, patients seldom … require scheduling and major transportation.

– “Caregivers truly ‘own’ their patients. … (They) admit their own patients and perform medical record coding and abstraction.

– “Continuity of care has real meaning—three-day stay patients no longer interact with 55 employees; they interact with fewer than 15.”

In a companion article, healthcare journalist David 0. Weber examines six hospitals following the patient-focused path. Most impressive is a 40-bed pilot unit within 897 bed Lakeland Regional Medical Center in Lakeland, FL. “(The) self-contained surgical service (includes) mini-lab, diagnostic radiology rooms, supply stockrooms, and administrative records/clerical area,” Weber reports. But the crucial innovation was organizing bedside-care around teams of “multi-skilled practitioners,” made up of a “‘care pair’—a registered nurse and a cross-trained technician—backed by a unit-based pharmacist, a unit clerk, and a unit support aid.” Each care pair handles up to 90 percent of the pre- and post-surgical needs for four to seven patients.

The unit’s nurses and technicians took a six-week, full-time course encompassing dozens of therapeutic and diagnostic procedures previously spread among myriad specialists. “Between them,” Weber writes, “the care-pair team would be competent to shoulder the full range of direct patient care, records processing, and hotel functions—from admitting, charting, charging, tray passing, transportation, and room cleanup to care planning, assessment, therapeutic intervention, diagnostic test administration, and outcome evaluation.” Special software (“Carelink”) and a computer terminal in each patient’s room aid the team in coordinating patient activities.

Among the dramatic results of the pilot effort:

– Turnaround time for routine tests dropped from 157 minutes to 48 minutes on average. For example, Weber explains, “Diagnostic radiology procedures were simplified from 40 steps consuming 140 minutes on average to eight steps taking 28 minutes.”

– Care pairs more than doubled the time they spend with patients, from 21 percent under the old system to 53 percent now.

– Fewer patient falls occurred in the patient-focused unit, the medication error rate was lowest in the hospital.

– The average patient encountered just 13 hospital personnel in the special unit, compared with 27 nurses, and 10 food-service, 6 ancillary service, and 5 central-transport workers in the normal scheme.

– Satisfaction levels soared. The unit’s registered-nurse turnover was the lowest in the hospital. “Physicians,” Weber writes, “unanimously hailed the improvements in test result turnaround times, reduced paperwork, and efficiency in making rounds.” Patient perceptions of quality, responsiveness, and empathy were far above average. (And costs fell noticeably!)

The clincher: Already well-managed and financially sound Lakeland will expand the model to 235 beds by 1993. “As radical and significant as all this is,” CEO Jack Stephens told Weber, “I believe we’re only scratching the surface.”

Hyper-specialization in hospitals is another, frightful result of the old “Fordist” paradigm. “Whatever economies of scale we might have achieved by centralizing (hospital services such as X-ray),” Lathrop concludes, “we more than gave up in the costs of coordinating and scheduling those services.” Once more, hidden, combined “soft costs” of coordination and staff de-motivation overwhelm the efficiencies analysts invariably promise from centralization and specialization.