The Health Care System Illness

Date: 11-23-08

With great frustration I have watched as the health care systems slowly degrade to the point that it is comparable or less than that of a third world country. This is an observation based on professional and firsthand knowledge over the last thirty five years.

In the past, when there wasn't a healthcare crisis (actually there has always been a shortage of healthcare workers), hospitals were run and managed by physicians and nurses. It wasn't until government regulation that hospitals found an overwhelming need to make larger sums of money. At about the same time (kind of like the chicken and the egg question, which came first, I believe, is a moot point now), came the realization that hospitals and the healthcare industry could be big business, generating large volumes of profit. This led to businessmen, lawyers, and boards of directors managing all aspects of hospital business including staffing and care of patients. With little or no knowledge of patient care or acuity of the patients, all decisions are now based on factual numbers generated by quarterly reports.

Generally, managing a business based on the compiled factual data is not only tried and true, but prudent as well. Any business that wants to remain in business must turn a profit; this includes nonprofit and charities, as well as hospitals.

The one factor that separates hospitals and similar types of businesses is the "human factor" of the equation. The "human factor" is the one unquantifiable factor that changes from minute to minute and is hard to justify when looking at profits and losses. This is the number of staff needed to perform the 'routine' tasks needed to care for the patient load. It is also the number of staff required to effectively manage any unplanned emergencies. Of course, some instances can be assumed, but generally are not, due to the fact that those are not consistent, and can not be added to the equation. Sadly, this is precisely the "straw" that broke the healthcare industry's back. This is one thing that has caused the "domino effect", and brought us to this point with the current crisis.

I have watched as many an institution having the potential to deliver cutting edge healthcare turns into just another mediocre, at best, institution that simply churns to make money. This cold and calculating method for providing healthcare is simply put, self defeating.

To understand why it is self defeating, whereas other businesses cannot hope to compete without this approach, you'll need to know what happens that is different.

In most industries it is a given that in order to stay competitive, a company must have as slim as possible the production to employee ratio without having employee burnout. Most innovative companies utilize multiple strategies to accomplish this task; such as using 'temp to hire' employees in order to see if the employee can perform to the company's standards. Incentive programs are implemented to encourage increased production. Another approach is empowerment of the employees, giving them reasons of pride and ownership to help increase productivity. In an environment in which production is relatively the same day to day, these methods are safe, and somewhat necessary to keep production high and personnel turnover low.

Now, this is why such methods have failed our healthcare system time and again; first and foremost, treating patients and their illnesses are unique to each individual. The methodology may be the same, but not all people understand, learn, or heal at the same rate. Secondly, unforeseen complications can and often do occur, depending on patient and family compliance and abilities, and sometimes for no apparent reason at all. Third, the fluctuations within each medical institution are unique to that institution, and are ever changing. Although, trending could graph out some of the possibilities, it would not allow for those items not trended, which then place the individual institution in jeopardy, and puts pressure on other institutions within that area, causing a domino effect within the healthcare system of that area, which can ripple out to effect other areas and so on. Fourth, the caring of patients is as highly rewarding as it is stressful. It is this on the job stress that causes another burden upon the healthcare industry. The stressful situation without resolve results in an inordinate amount of healthcare workers to leave their respective employers to seek a more rewarding institution, or leave healthcare altogether. This job jumping alone causes havoc within the system. Attrition away from the industry faster than replacements are trained also presents its own unique set of problems.

Due to the skill sets necessary, the constant turnover within each institution presents with increased costs for training and employee benefits. Also with high turnover of employees comes reduction in continuity of care. This results in longer hospitalization and less profits realized (due to the government regulations for payment of particular diagnosis or DRG's), forcing the institution to look for ways in which to recoup the losses. Since the largest outlay for most institutions is its employees, which is the first place management looks to cut costs. By doing this, it places even more stress on an already high stress profession. This one action has enormous and far reaching ramifications.

Some of the professionals simply migrate to other institutions.

Those professionals that try to perform under those (stressful) conditions find one or more of the following results:

1) Reduction in personal health, due to stressors, lack of sleep, improper eating habits, and dependence on drugs (prescribed and\or illegal).

2) Legal ramifications due to mistakes made from hastily making decisions or calculations; mistaken identity, misreading of labels, and this list could go on almost indefinitely, causing detriment to the professional, as well as the institution, and both reduce the profit margin.

3) Apathy, can that be said any more plainly? I have personally watched as management of several institutions have handed out assignments that were clearly unsafe and not achievable, yet the professional, documented that the work did indeed get done, sadly not only did the work not get done, but none of the work was done. Yes, it saddens me to have been witness to such happenings on many occasions. The other scenario is that the work is done in such a way that the patient's do not receive any benefits, again resulting in longer patient stays, and can have its own set of legal ramifications. Another is equipment failure or breakage from improper handling.

4) Employee injuries due to unsafe working conditions either caused by the worker trying to take short cuts or the company not providing proper work environment; or from faulty equipment.

All of the above mentioned scenarios have and continue to occur today, and as a result those institutions develop a poor reputation within their community. This results in enormous amounts of money funneled into public relations campaigns to try and offset public opinion. This shifting of revenues away from the clinicians further reduces available staffing; employee loyalty declines, and the search for greener pastures begins anew; when asked for recommendations as to which institution they would go to, the last institution they were with usually gets lambasted, further diminishing that institution's reputation, thus causing more advertisement and more aggressive PR, and the downward spiral continues.

To combat this some of the larger institutions have opted to increase the size and technology of the institution in hopes of attracting more physicians and specialist, thus, in theory increasing the patient base and reimbursements. The problem, though, has still as yet to be addressed, which is patient care. It does not matter how many or what type of patients an institution has, if there is not enough (quality driven) staff to care for the patients. The lack of adequate competent staff, also has its own inherent obstacles to overcome besides the obvious. When short cuts are taken, or numerous mistakes made it causes dissension within that field's members, and a lack of confidence between the different disciplines, thus inhibiting team work. This draws the focus away from direct patient care, and more toward finger pointing and self protection.

So what is the answer? First take a look (that would be called benchmarking), at a few different institutions that at first started off on the right foot. For now I will refrain from mentioning names and locations of specific individuals or institutions.

1) A medium sized hospital, new start up, that went from $5 million in building cost deficit (not to mention all the other related start up costs), to running in the black in less than one year. So how was the accomplished? Even though all of the equipment was new and state of the art, the bigger issue was staffing; not only was it better staffed than any hospital in its area, they recruited the best and paid premium wages and benefits as well. When word spread throughout the community, all eyes turned to see what indeed they were doing. Sadly though, corporate greed set in to see if the profit margin could be increased. They did this by first cutting staff. Then, the staff that remained started the migration away from that institution. They were forced to replace lost employees with less talented staff. Other methods of cost cutting ensued, but the staffing issue was never resolved. That institution has, to this day, never regained the reputation that it first enjoyed.

2) A durable medical equipment company (DME) that, although did not have the start up capital of the hospital, still started with highly qualified and motivated staff quickly went from a small business to a statewide influence and multimillion dollars in revenues, also tried to cut staff, and place more work on the staff than could be done safely. As a result, not only is that company out of business, but the owner is currently being prosecuted by the state for fraud.

3) A long term care facility that although did not have new state of the art equipment, they did have highly trained and motivated staff. The staffing ratio was second to none. The approach they took towards health care was a team approach; it was both innovative and aggressive. As a result, the majority of the patients that they cared for were able to recover and be discharged. The few that did not received quality care until they deceased, which also brought great comfort to their family members. This reputation allow for expansion and more facilities to be opened. Today, following corporate scrutiny, budgets for staffing are being reduced and the care for the patients is also being reduced. Now more patients die than are discharged, more lawsuits are being filed, more customer complaints are being lodged, and of course, the staff that was so good at what they specialized in have been migrating to other institutions. This migration has left this institution with more staffing problems and less than mediocre replacements.

In the end all of the above institutions (that are still in business), are still be rife with the problem of declining profit margins, declining reputation, and lack of quality health care. The obvious start of the problem is the search for increasing monetary returns. It has never been a virtuous endeavor to increase ones fortunes on the ills of another. Trying to make money on the backs of caring and dedicated people is also wrong in spirit. It has been said to me by wiser people than I, “there are things that are legal but wrong, and there are things that are right but not legal”, this has been good advice, it gives me hope when the system seems to be working against us. This is the crux of what is happening with the health care system.

To solve the current woes of our sick health care system, It will have to start where it began. The health care system needs to be revised to have more dedicated and selfless people that have vision and drive to ensure that quality is brought back into the system, even at the cost of loss of profit. It is only with that fortification that there will be any hope of attaining any form of quality health care.

With an excellent healthcare system comes a great many benefits other than the obvious. Better staffing will result in the ability to perform at a higher efficiency with more aggressive care. Becoming proactive will result in fewer resources spent on reaction. This will result in shorter patient stays within hospitals, and greater care outside the hospitals, allowing for eventual higher profit margins. With a healthier community there are fewer burdens on resources. More improvements can be made on community infrastructure allowing for growth within that community. This growth of the community will spur advances in medicine and science; which will allow for even better healthcare and quality of living.

Contrary to popular belief, the differences and functions within the different disciplines are not so dissimilar. At the forefront are the physicians, who unlike other clinicians are more geared towards diagnostics than actual patient care, although they are taught how to perform specific clinical tasks (like giving shots), their skills are poor at best due to the lack of practice, except possibly surgeons. Nurses on the other hand are thought of as subservient to the physicians, which couldn't be further from the truth. Nurses are a key and integral part of the healthcare system, not only do they perform the menial tasks, but have unparalleled skills in performing those that requires dexterity, and attention to detail. But not to be dismissed are the diagnostic skills of nurses, for unlike physicians who look towards the symptoms of the problem, a nurse's approach will more often be holistic and try to bring all of the bodies function to normal. Therapists of various disciplines focus on body specific areas. Then there those that go unseen for the most part because they are not always involved with the day to day care.

Currently all of these disciplines are at odds with each other to some level. Of course none of the professions would admit to this, but none the less this is an unspoken known within the healthcare community. This animosity towards each other and lack of respect lends to the healthcare crisis. Society has played a very large roll albeit covertly, in so much as setting the physicians stature far above other healthcare workers. There has always been unease between nurses and physicians, where and when it began is unclear, but has been perpetuated by both individuals, and the professional associations of each for quite sometime. Nurses have been uneasy about any other ancillary healthcare workers taking an active roll in carrying for 'their' patients. This is a carry over from when nurses were held ultimately responsible for the condition of their patients. This was also taught in most nursing schools until recent times. Slowly nurses are beginning to overcome this mindset as more competent and skilled ancillary staff gains their confidence.

It will take the combined cooperation of all healthcare workers and administrators working with and through the government to overcome the current crisis. Only through this collaboration, and big changes made in the freedom to treat the illnesses, along with more diversity in the scope and practice of bedside clinicians will great advances in healthcare be realized. It is only through freedom, diversity, and levity will the burden of the work load of all be reduced to a manageable amount.