The Future: Hospital Systems Post COVID

June 8, 2020 by David Nitkin | Categories: Scenario Development and Testing | Tags: employment, morale

The Issue

In a mere four months, the coronavirus (COVID-19) has driven tens of thousands of people to hospitals in many nations. Thousands have died there, despite best efforts to enact social distancing to help flatten the curve of admissions. Hospitals have emerged with lots of analysis and criticisms to their role in fighting the first wave pandemic. This post tries to assess what worked, what needs to change, and whether the traditional model of the hospital can and should change.

Hospitals as Hub Institutions

In total, there are over 1,400 hospitals in Canada, 500 of which are found in the province of Ontario. Hospital expenditures per capita appear to be highest in less populated territories. In 2018-2019, the greatest expenditures for hospitals in Canada were staff compensation and supplies. Research, education and other areas accounted for just over 10 percent of expenditures during that time. The hospital with the highest research spending in Canada is the University Health Network located in Toronto, Ontario.

In general, hospitals function as the hub of intensive care in Canada, with an integrated link between emergency transport, internal research and testing, in-patient major surgery, and post-discharge recovery. The average length of hospital stays in Canada appears to be on the decline. Common reasons for hospitalizations in Canada include child birth, Chronic obstructive pulmonary disease (COPD), pneumonia, heart failure and mental health disorders. Canadian hospitals host a large share of all surgeries performed every year. During fiscal year 2016-2017, the most common surgeries were C-sections, knee replacements and hip replacements.

In 1980, the average number of hospital beds in Canada stood at 6.75 per one thousand inhabitants. By 2018, this rate had decreased to 2.5 per every thousand population. In 2011-2012, 8,332 people per 100,000 population were hospitalized, and in 2017-2018, the rate had dropped to 7,944.

By their nature, hospitals are different beasts from other property types. Elevators are large enough to accommodate patient beds, for example, and conspicuous signage and wayfinding are a must in what is usually a large, labyrinthine structure. Everything in a hospital is fine-tuned, even down to the doorknobs. All of the attention to detail is no match, however, for a global pandemic like COVID-19. As we face a shortage of ICU beds and construction of temporary hospitals, it’s clear that our health-care system is going to have to react—not just to face this current crisis, but those that experts say may occur down the line.

Recommendations for Changes Based on COVID Challenges

The literature on proposed, necessary changes in the role, scope of services and management of hospitals as exposed by the experience with the virus is large. Among the more interesting ones are these:

(a) Reconsider the traditional “hospital as hub-for-care model”, moving from institutional to patient needs focus—hospitals should not be one size fits all for all needs.

(b) Involve clinicians in future design and planning, so they can contribute to help think through potential bioterrorism and pandemic scenarios.

(c) Design an ergonomically-sound sanitization, circulation and health monitoring system using best infection control principles for staff as well as for patients and visitors—including de-densified offices, sanitation stations, thermometer entry, rest rooms, one way corridors and separate research staff desks

(d) Accept flexible capacity evidence-based hospital design in order to expand both emergency department capacity, other designated spaces (hospital underground parking, cafeteria, lobby) and the number of isolation rooms when needed.

(e) Utilize heating and cooling system contractor expertise to allow for enhancements like negative pressure, infection containment spaces or rooms. This includes being able to isolate different areas of the hospital with separate air handler units and air filtration systems to mitigate cross-contamination.

(f) Rethink hospital visitation from start to finish, including:
- i. video chat and virtual reality headset technologies,
- ii. microphones to do remote personal condition assessments, and
- iii. smart forehead thermometers.

(g) Apply new hospital designs that help patients stay connected to friends and family by incorporating widely available technologies such as video chat and virtual reality headsets. In the pandemic, many patients and health care workers have benefitted from shared stories detailing the emotional pain associated with long, lonely hospital stays.

(h) Explore the adaption of and installation support for all manner of personalized self-imaging technology such as:
- i. smart watches;
- ii. sensitized plaster band aids;
- iii. locational tracking computer device apps; and
- iv. chatbots.

(i) Employ value-based procurement (VBP) principles, which focus on providing health products and services of the greatest value — that is to say, the best outcomes at the lowest costs, not just the lowest cost. Hospital procurement policies were developed with good intentions — standardization and cost savings — but can be counterproductive to acquiring the short- and long-term clinical and economic benefits of new treatments, services, and technologies. In picking the lowest sticker price, we don’t always end up with greater long-term savings and outcomes

(j) Adjust hospital and health care budgets and behaviours to reimburse and incentivize value-added and values-based innovations.

(p) Change current physician remuneration system — in which doctors are incentivized for tasks instead of outcomes, where they usually have to see a patient in person to get paid, and department budgets are allocated in silos. Under this model, there’s no incentive to have less expensive health care providers, to use virtual visit options, or to adopt innovations that might cost more in one department but result in overall savings for the hospital or health care system. Rewarding the volume of services — rather than their value — discourages the adoption of innovative technologies or new ways of working.

Operational Changes

In terms of operational details changes developed as part of the EthicScan Scenario Development and Testing Sessions, these changes might find expression in these ways:

(a) Plan for and implement digital platforms to conduct more services from various away-from-hospital locations, including tele-visits, training, and testing.

(b) Establish linked networks for home care, rehab hospitals, nursing homes, seasonal flu clinics, shelters, and primary care inpatient rehabilitation facilities.

(c) Integrate clinical care with social services, housing, counselling, opioid treatment, and various other non-clinical services.

(d) Explore public-private partnerships: pharmacies, robotics cleaning and delivery, tracking and tracing.

(e) Engage in emergency preparedness planning, anticipating temporary surges in demand every five or 10 years, including contingency plans to set up tents and temporary quarantine areas on hospital grounds and negotiating the use of additional space inside nursing homes, assisted living facilities, hotels, religious centers, and colleges.

(f) Adopt better designed, separate stream, screening for patients to quickly separate suspected COVID-19 patients from others and direct them to isolated parts of the hospital or other treatment locations.

(g) Implement touch-free controls: Hospital designers and architects are discussing the need for touch-free control for lighting, temperature, and other building functions, to help avoid spreading diseases on these highly used surfaces.

(h) Choose a smarter selection of building materials: Building with materials that are less hospitable to microbes, such as copper, may reduce the risk of surface transmission.

(i) Eliminate window curtains, which can become easily contaminated, by installing windows made of e-switchable privacy glass — also known as e-glass or smart glass — which can switch between translucent and opaque and are easy to clean.

(j) Reduce or eliminate staff shared space areas: Hospitals have already moved toward eliminating sleeping quarters for hospital staff and reducing the number and size of break rooms and rest areas.

(k) Design and offer a range of integrated human resource incentives (tax rebates, emergency housing, shopping services, counselling, recognition and rewards, transport) for essential front-line emergency and regular health-care staff.

(l) Apply bedside machine-learning technology: The use of chatbots, or “doctor-less” screening is another means to potentially ease the load on clinicians. Patients concerned about symptoms can ask for guidance and the algorithmic system can respond with the most useful answers based on what worked best for others.

(m) Prioritize minimally-invasive surgery like aortic valve replacement, trans catheter aortic valve implantation, and other proven innovations that could reduce the length of hospital stays, or the likelihood of infection.

(n) Develop a supply procurement and distribution plan for personal protective equipment (PPE) and biomedical equipment (including oxygen, ventilators), including a contingency plan for shortages.

(o) Train all staff for safe COVID-19 recognition and care.

(p) Dedicate transfer vehicles and ambulances for all suspected or confirmed COVID-19 cases. Ensure that IPC measures are always respected during patient retrieval and transport, and that vehicles are disinfected properly.

(q) Consider establishing expanded screening and appropriate referral pathways in community settings (for example, fever clinics).

Conclusion

With effective leadership, collaboration, and a commitment to a new way of looking at innovation, Canada can aspire to reshape its hospital care system and effectively meet the health challenges of our times, today and in the future. That future will likely include more frequent discontinuities like contagion and natural disasters. Hospital design, management and planning should not take place in a vacuum and these suggestions (among others) need to be considered as part of changes to all the elements of institutional and community care. The above ideas drawn from a Trends, Forecasts and Outlooks paper for hospitals are important candidates for planners to use in scenario development and testing.

David Nitkin, founder of EthicScan, is a full-time organizational ethicist. David’s original writing, teaching, consulting and research focuses upon ethical decision making; enhancing corporate accountability and reporting; and developing corporate ethics assurance programs, including transparency, risk management, integrity management, and safe partnering.

David has provided ethics training, advice and research for over 200 clients both internationally and in Canada who collectively employ over 750,000 employees. He consults and trains widely with a variety of clients, including corporations, industry associations, public service sector organizations (integrity commissions, human rights commissions, and anti-corruption tribunals social agencies, professional ethics certification organizations, not-for-profits; and civil society organizations.

The Issue

Hospitals as Hub Institutions

Recommendations for Changes Based on COVID Challenges

Operational Changes

Conclusion

Further Reading