1. 2. 3. 4.

Discuss the history of hospitals and hospital care. List and discuss sources that shaped the hospital industry. Identify and describe types of hospital ownership. Identify landmark Studies of Quality of Hospital Care.

HITT 1345 Health Care Delivery Unit 02 - Hospitals: Origin, Organization, Performance This Units overview of the genesis of U.S. hospitals provides a basis for understanding their characteristics and organization. The major private and governmental insurance initiatives that contributed to the growth and centralization of hospitals in the health care system are also defined. This unit will also discuss the diverse functions of hospitals from their beginnings through today. The unit concludes with a discussion of the quality of care provided in hospitals. Of all the familiar institutions in U.S. society, the hospital is, at the same time, the most appreciated, most maligned, and the least understood. Besides serving as a place for the sick and injured, it may function as a research laboratory, an educational institution, and a major employer in the community. The hospital dates back to the earliest history of health care in the United States and was originally intended as a place to shelter older adults, the dying, orphans, vagrants, and to protect the inhabitants of a community from the contagiously ill and dangerously insane. During the eighteenth century what passed for medical care at the time was provided in the home. Larger cities, such as Boston, Philadelphia, and New York opened some of the first hospitals in an effort to protect their inhabitants from contagious disease. Bellevue Hospital, established in 1736, was originally the Poor House of New York City. In 1789 the Public Hospital of Baltimore was established for low-income populations, people with mental or physical illness and the seafaring of Maryland. One hundred years later, in 1889, it became the now prestigious Johns Hopkins Hospital. Eventually, most major cities in early America opened such institutions. The early nineteenth century found most U.S. hospitals to be filthy, unventilated, and contaminated with infections. They offered little or no medical treatment until the movement by Protestant and Catholic nurses. It was the Civil War that brought appreciation to the field of nursing along with true and compassionate

medical treatment. Unfortunately, hospitals also became institutions where the poor and insane could be used as specimens for research and educational purposes. Surgeons practiced and perfected many surgical techniques. Internists tested treatments, and the field of obstetrics found its origin. Over time, however, focus shifted more towards patient focused medical care involving a care team of physicians, nurses, and other allied health professionals. The changes that have followed are due to a number of factors. As we touched on in Unit 01, the advent of health insurance greatly affected the delivery of health care in the United States. By the 1960s, billions of dollars were flowing into hospitals from insurance companies such as Blue Cross. The availability of hospital insurance removed an important cost constraint from hospital charges. Expanding hospital services and a relatively unrestrained reimbursement rates created an inflationary spiral that persisted for decades. In addition medical advances and specialization expanded following the development of new technologies and drugs. Many new treatments and surgical technique resulted from military needs in World War I, World War II, the Korean and Viet Nam conflicts. In an effort to provide services for older adults, children and the indigent while controlling costs, Title XVIII (Medicare) and Title XIX (Medicaid) of 1966 Social Security Act were passed. You have learned about these entities in detail in HITT 1301 Health Data Content. For our purposes, it is important to understand that these two acts influenced the delivery of health care and greatly restricted hospital reimbursement. From here came the movement to managed care and the delivery system we see today. The result for hospitals has been a decrease in reimbursement when the costs of providing treatment continue to rise. This has lead to closings and serious cutbacks at a number of hospitals across the country. This seriously impacts the finances involved in operating a hospital regardless of the type of hospital ownership. Acute care hospitals are operated under three types of ownership/sponsorships. 1. Voluntary not-for-profit example: hospitals owned and operated by religious orders 2. Profit-making corporations example: HCA facilities 3. Governmental jurisdictions example: Veterans Hospitals, and Public Hospitals Hospitals may be further divided into teaching or non-teaching facilities Teaching hospitals are affiliated with Medical Schools.

A major concern as the changes continue is how they impact the quality of patient care. For many years, quality was defined as the degree of conformity with preset standards and encompassed all of the elements, procedures, and consequences of individual patient-provider encounters. Most often, however, the standards against which care was judged were implicit rather than explicit and existed only in the minds of peer evaluators. Peer review in the form of chart auditing was used until the early 1970s to make judgments as to the quality of patient care. A move was made in the 1960s to look specifically at three basic components of health care: Structure the qualifications of the providers, the physical facilities, equipment and other resources Process What occurred during the hospital stay? Intensity of service based on severity of illness Outcome all of the things that did or did not happen as a result of medical intervention There are several landmark studies of quality of hospital care. These studies are important as they make a strong case for the standardization of medical care that has resulted. These standards account for factors such as age, sex, severity of illness, accompanying conditions and other factors that might influence outcome. For our purposes, we will look at two studies. 1960s Columbia University School of Public Health. This was a study of the quality of health care provided to members of the Teamsters Union in New York. Teams of medical experts reviewed large samples of patient records to decide if medical treatments were justified, appropriate, and acceptably provided. 1973 John Wennberg & Alan Gittlesohn. These two researchers published the first of a series of papers documenting the variations in the amounts and types of medical care provided to patients with the same diagnoses living in different geographical areas. The study emphasized that the amount and cost of hospital treatment in a community had more to do with the number, specialties, and individual preferences of the physicians than the medical conditions of the patients. At the same time as the 1973 study, the Social Security Act was amended to create a national network of local Professional Standards Review Organizations (PSROs). PSROs were charged with ensuring that health care services purchased in whole or in part by the Medicare or Medicaid programs conform to appropriate professional standards that are delivered effectively and efficiently. PSROs

reflected two longstanding societal assumptions about the quality of health care reviews: 1. Providers are the most appropriate evaluators of the quality of work of other providers 2. Because of regional variation in practice patterns, the review process must be local to be most effective. Both of these assumptions were subsequently found to be faulty. What was clear, however, was the expectation that physicians would take this opportunity to demonstrate that they could assume responsibility and accountability for monitoring the quality of medical care in their geographical regions.