More Democracy in Hospital Management

by Vadim Shteyler

Interdisciplinary collaboration between all healthcare professionals involved in an individual patient’s care has been increasingly recognized as vital for providing high quality medical care. However, when it comes to hospital management, decisions affecting daily workflow are still largely made by physicians.

The movement towards an inter-professional team approach of providing medical care is still new but gaining widespread support. To characterize the disconnect between the presence of inter-professional collaboration in medical care, but its absence in healthcare management, it is valuable to understand the rationale for inter-professional teams in healthcare. 

There has often been little communication between a patient’s generalist and specialist, and even less communication between physicians and other health professionals (often termed “fragmentation of care”). Numerous delivery model changes exemplify health professionals’ growing efforts to provide comprehensive, coordinated, and interdisciplinary care: Patient Centered Medical Homes (PCMHs), for instance, aim to link many different health professionals together (i.e., primary care physicians, specialists, nurses, social workers, mental health providers, etc.). Many clinics, recognizing that each professional adds a unique perspective, bring all of a patient’s providers together so everyone can contribute to creating a care plan. On some inpatient hospital services, in an effort to ensure good communication and incorporate nurses’ input in daily care plans, many physicians and nurses have begun rounding together. The more traditional, and all too common, alternative has been physicians paging nurses from the opposite end of the same workstation.

It is increasingly believed that implementing these changes will improve patient care; improving communication between providers will allow for the most complete understanding of a patient’s situation and condition. By reducing repeat and unnecessary testing and prescribing, they help reduce costs. By linking team members from different traditions of patient care, they help providers learn from each other.

Unlike in medical decision-making, physicians have not always had such a large role in management decisions. Incorporating their views into medical management is an important first step. Physicians directly care for patients and, through management, can report and fix the systemic problems and inefficiencies that they see. Partners Healthcare, for instance, has groups such as the Massachusetts General Physician Organization that give physicians a voice in hospital policies and management decisions, and reserves executive positions for physicians. Chairs of departments often gather physicians for input on administrative changes as well.

Though some argue that physicians ought to be “Captain of the Ship,” I believe that if healthcare workers from all professions would be able to contribute to management decisions, hospitals and physician groups would run more efficiently and provide better quality, more cost-effective care.

Management decisions should not only be made by the individuals with the most medical expertise. Rather, management decisions should be made with input from all people who affect the daily workflow of clinical practice. Many health workers who have a dramatic impact on workflow and patient care are never even seen by physicians. In the operating rooms (ORs), for example, the crew that cleans, sanitizes and sets-up the ORs between surgeries dramatically impacts the patient volume and cost of running a surgical department (estimated at 2-40% of total hospital costs)—one wasted minute in an OR cost approximately $60-100. The OR cleaning-crew, however, is seldom invited to contribute to ways in which ORs can run more smoothly. Phlebotomists collect blood for daily blood tests on virtually all patients, and yet, like the clean-up crew, they rarely communicate with clinicians. Actually performing laboratory tests on blood samples is usually a quick process; most of the time taken to get results of the tests that physicians order is in drawing the blood and transporting it to pathology labs. Frustrations at blood test inefficiencies lead many physicians to mark all of their ordered laboratory tests “STAT”, ensuring they will be prioritized in processing, but exacerbating the backlog of other blood tests.

Making a hospital into a more democratically managed institution would also make workers feel that their work is more meaningful. It would provide workers with a greater feeling of autonomy and empower them to make changes in their work environments. In many ways, developing systems that would encourage all worker participation in healthcare management would not only be more efficient and cost-effective but also more ethical.

The Petrie-Flom Center Staff

The Petrie-Flom Center staff often posts updates, announcements, and guests posts on behalf of others.

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