Evolving Healthcare Trends

The model trends in the healthcare system have been changing over the period of time. The old trend gave importance to the individual patients and the emphasis was on treating illness. The goal of the hospitals was to do inpatient admissions, fill up the beds and more emphasis was given to acute inpatient care. The role of managers in the old paradigm was to run the organization and coordinate services. In the old system, all providers were essentially the same. The hospitals, physicians and health plans were separate and not integrated.

The newer trends that evolved gave importance to the population as a whole. It not only treated illness, but emphasized on promoting the wellness of the people. The goals of the healthcare system after being transformed over the years is to provide care at all levels which is continued. The role of managers in the new paradigm is more broad. They see the market and help in quality and continued improvement. They not only run the organization, but also go beyond the organizational boundaries. In the evolving system, the providers are differentiated according to their ability. The hospitals, physicians and health plans have formed an integrated delivery system.

One of the current trend in the healthcare delivery model is that continued care is emphasized. The key professionals are not only treating patients for their illness, but they are promoting and managing quality of health. For example, a patient with high cholesterol visits a doctor. He is not only given one-on-one medical treatment, but he is also offered to attend a group session where information is provided on how lifestyle and behavioral change can help. The patients learn from the clinicians and also from each other. Another current trend is to take care of the health of the defined population and not only individual patients. All the health needs of the population as a whole are identified and served. It is emphasized that the community uses the health and social services provided. Healthcare has become more population-based. Another trend that has evolved is that the hospitals, physicians and health plans have got connected and have formed an integrated delivery system. More investments are being made with a goal of providing services to the customers and retaining them.

There is a beneficial impact in the transformation of healthcare towards emphasizing continued health. The way healthcare has been viewed in the past has been changing. The shifting of care from treating acute illnesses to providing continued care is resulting in enhancement of the health of the people. The only appropriate and feasible model is to provide a continuum of care with the emphasis firmly on the family and community. The health of the population and community is considered as a whole. This is advantageous as it creates value in the healthcare delivery system. The healthcare providers work with the community as a whole and consider to improve the health of the general population. Even though this requires new kinds of ways of organizing and managing healthcare services, it helps in understanding the health needs of the target population. By studying their needs, the right health and social services could be provided to them. Examples of promoting wellness of the whole community are organizing health campaigns and providing preventive education to the people in general. Another example is providing awareness about flu vaccines and encouraging people to get the vaccination.

Integrating the healthcare delivery system has led to certain advantages to the patients. For example, they can be offered alternative sites of care depending on their convenience. It helps in meeting the needs of the customers and their preferences which is taken into account. The number of providers are expanded and the patients get to have a choice. The relationship between providers and health plans are organized in the current trend and this ensures that the right care is provided in a convenient way to the customers.

There are defined budgets and expenditure targets for the populations which implies that there is a need to be efficient and productive. The formation of strategic alliances, networks, systems and physician groups can also add value. There are capitated payments and budgets allotted to the healthcare organizations. These are used to provide care to the defined population. The organization might like to improve on the payments and budgets as the expenditures of the companies increase. This results in the management to make decisions like forming strategic alliances with other organizations and increase the total resources. The growth of such networks will help in providing better care to the customers. Financial resources greatly influence the efficiency and productivity of the organization.

The aging population is influencing the healthcare delivery. There is increased demand for primary care of people over 65 years and for chronic care of people over 75. The ethnic and cultural diversity is also influencing the healthcare delivery. This provides a challenge in meeting patient expectations on one hand and diverse workforce on the other. Biological and clinical sciences have met with technological advances and have led to new treatment modalities. This has led to open new treatment sites and manage across the organization. External forces change the supply of certain areas of health professionals like physical therapy and some areas of nursing. The management needs to compensate for such shortages and they need to develop different teams of caregivers at different work sites. Changes in education of health professionals implies that the management be more creative in offering healthcare services. With an increase in diseases like AIDS and morbidity from drugs and violence, there is more and more need to work with community agencies, form social support systems and there is a need for more chronic care management. Advances in information technology is another area where there is a need to train the healthcare employees in new advances. They also need to manage issues of confidentiality and rapid information transfer. Increasing expansion of world economy has led to more competitive management of strategic alliances, care of patients across the nations and of different cultures.

Current environmental trends impact the healthcare delivery model. Organization’s success depends on its external and internal environment. The complex environments made up of uncertainties and heterogeneity of components leads to different organizational designs. The current environmental trends influence managerial and organizational decision making. The unique challenges facing the healthcare delivery organizations should be analyzed in order to develop and implement new and effective operational processes and strategies. As an impact of current environmental trends, the healthcare delivery system needs to improve individual, team, and organizational accountability and performance. The impact of advances in medical knowledge and information technology on the process of healthcare delivery should also be examined, and it should be leveraged to improve quality of care, process and cost controls, and revenue. New strategies would need to be identified and implemented for learning and performance improvement to create a culture that supports accountability, safety, and high-quality care. Innovative models in healthcare delivery would also be required in order to develop and implement strategies that promote organizational success and competitiveness.

Due to the current environmental trends, more emphasis is given to the customers and there is more of a patient-focused care. The healthcare delivery model has been shifting to the community based care. There has been an increased modification in care processes. The traditional ways are being challenged and more experiments are being performed to fulfill the demands to improve the quality of care. Due to the shift in the environmental trends in the healthcare delivery model, more emphasis is given to quality improvement. This will help improve the performance levels of key processes in the organization. The performance levels are being measured, the defects are eliminated and new features are being added to meet the customer’s need efficiently.

There is a new emerging contemporary trend in the U.S. healthcare system. Presently, the management research and assessment have been offered increased recognition. The emerging trend seen is that this is slowly forming an integral part of managerial and organizational effectiveness. With the emerging efforts in information management, it is leading towards clinical and financial networking. The trend seen among the physicians and nurses is that they are being increasingly involved in managerial activities. The managerial trends are also changing with respect to role performance and changing values. The managers role is getting more and more recognized in managing finance and human resources. Management training, lifelong and distance learning is being offered in preparing future managers.

The healthcare executives and managers will be faced with the major responsibility and challenge in the years ahead. They will be working with other healthcare providers and will be creating a competitive future for their organizations. They will not only be managing organizations but also a network of markets, services and joint ventures. Formation of more and more strategic alliances and partnerships will lead the management to manage across boundaries. The management will change from managing a department to managing the continuum of care. The management will be following a community-based approach. Trend in management is also shifting from just coordinating services to providing improvements in quality.

As the demands in healthcare are increasing, the management is responsible for forming performance standards. The management is also challenged to maximize the productivity and quality to serve the health needs of the community. The management is looking after the demands of the external environment as well as attending to the performance of the internal environment. The management is responsible for the performance of the organization.

Healthcare organization leadership will be responding to new trends and competitive forces. It will respond to continuum of care, overall health status of the population and more complex organizational structures. These emerging trends in the healthcare system will effect the organization’s leadership. The future managers would need leadership skills and vision to integrate the organizations and help in providing the best care. The managers will have to be committed to leadership and work on giving their organizations the best place and help their organizations adapt to the changing circumstances. More value will be given to leaders who will be able to lead the change process. As changes are inevitable for the betterment of the organization, the leaders should be able to identify how the change is to be received and how it is to be communicated at all levels of the organization without damaging the implementation process. The leaders might have to deal with increased pressures due to organizational complexity.

The leader in the organization provides strategic direction to the organization, manages diverse stakeholders, becomes mentors for management, is willing to take risks, helps the organization interact with the external environment and attends to the internal needs as well. Where required the leader will involve physicians in governance process and align physician and organizational interests. There will be a need for formation of learning organizations. Transformational leadership will create the required vision for the organization. Leaders will have a greater role complexity and they themselves will have to adjust rapidly to new situations. The healthcare organization leadership will have to live up to the values of the organization and will help in fulfilling the mission of the organization.

Individuals and groups within the healthcare organizations require more and more competencies. An enhanced lifelong learning is required due to the fast, changing environment. The individuals and groups within the healthcare organizations will be benefitted as there will be rapidly developing medical technologies which will result in increased services. More sophisticated health services will be provided to the consumers. The range and quality of services provided will be regulated for the benefit of people requiring home care, long term care and ambulatory care. The anticipated future development will also result in the increased competition among the health services organization. The individuals and groups will be involved more and more with the community for issues like drug abuse, teenage pregnancy and violence.

Best Practices For Hospital Peer Review

When done properly, peer review is an important process that helps hospitals and their doctors ensure consistent, high quality patient treatment. Hospitals can identify at-risk physicians; physicians can help improve quality of care for patients. Why is this process so difficult? It’s simple – hospital politics, economic advantage and personalities.

The current physician peer review system, created by Congress in 1986 through HCQIA legislation, was intended to promote higher quality patient healthcare. Unfortunately, Congress did not foresee that hospital peer review actually puts physicians into an environment where political, economic and personality conflicts can easily render the process ineffective. Nor did it foresee that hospitals would sanction doctors for speaking up on behalf of patients regarding quality of care concerns.

In the hospital environment, peer review is considered an ugly task that is just one more action item for a busy medical staff and is easily pushed to the bottom of the priority list. Often it just doesn’t get done. Why?

Physicians on peer review or quality management committees too often find themselves in conflict of interest situations. They compete for the same limited geographic pool of patients and for professional recognition within a very narrow specialty. There may also be personality conflicts with the physician under review or pressure by their hospitals not to seriously scrutinize a fellow physician who has stature in the medical community. The tight-knit social and professional relationships found in a hospital environment can lead to bias and reluctance to pass judgment on associates. This reluctance tends to lead to unusually long delays in resolving critical quality management issues. By the time a critical situation is actually dealt with, the costs and risks to a hospital or group can be catastrophic.

Backlash

The breakdown in a hospital’s quality management system can be very damaging. Inadequate peer review can result (and has) in negative consequences for hospitals and hospital groups, such as:

o Negative publicity

o High profile lawsuits

o Multi-million dollar fines

o Management shake-ups

o Loss of investor confidence

o Damage to physicians’ careers and practices

o Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

sanctions and loss of accreditation

o Scrutiny by state and federal agencies and other public organizations.

These negative events, combined with rising consumer frustration with the healthcare system, make it increasingly imperative that hospitals pay close attention to their quality management and adopt best practices whenever possible.

Peer Review as a Risk Management Tool

A well-executed peer review process can easily avoid such negative events by using best practices in risk management. The earlier a physician performance issue is detected and dealt with, the lower the costs and potential negative consequences to the hospital and the physician.
Basing effective peer review on medical evidence and adhering to the intent of the law — to improve the quality of patient care — helps discover, highlight and deal with quality problems quickly and efficiently. Issues surrounding internal politics, competition, and personality conflicts should be considered when setting up a peer review committee.

Involving Outside Parties in Peer Review

The most effective quality management process involves using a “neutral” outside party in addition to the hospital’s own peer review committee. This neutral party can review sensitive cases where there is a potential conflict of interest. Hospitals with the need for an outside case review have often turned to affiliated hospitals or searched for “like” specialists through personal connections. While this is an effective method for solving the problem, it has its own set of challenges:

o How do you quickly locate the right specialist?

o How do you convince them to take time to do a peer review?

o How long do you have to wait to get it done?

Unless you have a well-developed process and pre-arranged agreements with affiliates or physicians to perform peer review, it can be very costly and time consuming to arrange for this each time it’s needed.

IROs: A Cost Effective Solution for Hospital Peer Review

Many hospitals, today, are turning to Independent Review Organizations (IRO) to aid in fixing their peer review process. An IRO serves as an objective third party that can provide hospital peer reviews based upon medical evidence and improve the fairness of the process for both physicians and the hospital.

An IRO can match doctors with the right specialist expertise to effectively review sensitive cases and reach an unbiased determination. Reviews are conducted by board-certified physicians in active practice, who are usually located in a different state than the physician being reviewed. Hospitals pay only for the reviewing physician’s time at pre-determined hourly rates.

Because these specialists are already on board, reviews can be completed in much less time and at significantly lower costs. Peer reviews are conducted using a standard reporting format, and the typical turn-around time is less than 21 days. Since IROs review thousands of cases annually, per case review costs are kept to a minimum.

An IRO can give peer review the high priority and timely consideration it deserves — without impacting the hospital staff or tarnishing a hospital’s reputation.

Using an IRO for objective peer review may be one of the best solutions for helping hospitals get back to the intent of the law – improving healthcare quality for patients. An IRO can also help reduce costs, avoid expensive litigation, enhance hospital reputation and protect JCAHO certification.

Peer Review Best Practices

To ensure an evidence-based outcome for peer reviews, hospitals should consider this nine step process:

1. Develop a culture of accountability within the hospital.

2. Make sure that the peer review process is well defined, understood, accepted and adhered to by all.

3. Watch for “sentinel events.” Bring patterns of recurring or clustered problems to management’s attention in a timely way.

4. Assure that questions posed during the process are precise, and that responses are precise as well, including the hard questions, with rationale and associated guidelines.

5. Make sure that each peer review case is reviewed by a “like” specialist

who is unbiased and has no potential for conflict of interest in

rendering an opinion.

6. Make sure the peer review committee meets monthly and that cases and replies are distributed, reviewed and responded to in a timely manner.

7. Make sure there is a re-review of each case after the subject physician input has been received.

8. As much as possible, conduct all reviews in a non-accusatory and

professional format.

9. Systematically send your most sensitive peer review cases out to an Independent Review Organization.

Choosing the Right IRO

Choosing the right IRO as a partner for hospital peer review can be as confusing as the process itself. Here are some simple questions to ask in the selection process:

1. Is the IRO URAC-accredited? – There are dozens of companies

that claim to offer medical review services. There are only a few

that are actually accredited by the American Accreditation

HealthCare Commission, also known as URAC. By selecting an IRO

with URAC accreditation, the hospital partner with a standards-

based organization can deliver the quality and objectivity

needed for the peer review process.

2. What types of doctors are on staff at the IRO? – It’s extremely

important to work with an IRO that has doctors on staff trained to

make fast decisions, who are board certified and still in active

practice.

3. How deep is the IRO specialty panel? – The IRO under consideration

should be able to deliver the specialists needed on a moment’s

notice. Not only do these physicians need to be in the same

specialty, but also from the same type of institution. A heart

specialist from Los Angeles may not be the right physician to review

a related case coming from a rural hospital in Iowa.

4. What are the standard turn-around times? – The IRO selected

should have a strong track record of turning around reviews quickly

and accurately. Find out what the average turn-around times are

and what process the IRO offers for expedited reviews. A standard

of 21 days or less for hospital peer review should be the minimum.

5. How accessible are the IRO physicians? – Many IROs offer basic

peer review services. The best IROs, however, are the ones that

truly act as partners to the hospital peer review committee and

make themselves fully accessible to the physicians under review. By

becoming a part of the process, the IRO can truly act as the neutral

third-party and help keep the relationships between all parties intact.