Leadership Recovery: The Future of Hospitals

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The Issue

The hospital sector has undergone many changes since the coronavirus pandemic hit. There has been much learned about the nature, treatment and hospital response to the virus in the first wave. In particular, there are a number of Trends, Forecasts and Outlook lessons learned internationally, not just in North America. This blog provides an update to the literature review that covered expert published public reports issued in the period 15 March-30 June. It deals with professional literature published in the period 1 July-15 October.

Big First Wave COVID  Issues Facing Hospitals

According to industry insiders and experts, we cannot return unchanged to a hospital-centric delivery system in the “new normal” hospital of the future. The big issues they raise include:

  • Is the traditional concept of a generalist hospital still fit for purpose in the 21st century?
  • How can we ensure that future hospital-building is pandemic-proof, while still representing good value for taxpayer money?
  • In light of new models of care delivered outside of hospital settings during COVID, do we need to rethink how hospitals provide outpatient care?
  • How can high volume, less siloed and specialist treatment be best delivered?
  • Should critical bed capacity be maintained at current levels, return to pre-pandemic levels, or be increased further still?
  • What is the likely future for emergency field hospitals established as part of the COVID-19 pandemic?
  • How can new hospital construction be better integrated within the local health and social-care system?
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One major wave one lesson is not to focus on COVID to the detriment of other diseases. The perilous deferral of needed services has led to later hospitalizations requiring higher levels of care, longer lengths of stay, and increased hospital re-admissions, thereby further straining hospitals’ inpatient capacity. Some experts advise that it is critical to not only focus on the acute care of COVID-19 patients, but also proactively manage patients without COVID-19. This is true particularly for those with time-sensitive and medically complex conditions whose care has been postponed in order to manage the ICU bed availability curve. This is important not only to sustain health and life, but to preserve future hospital capacity.

Building for a hospital system’s future means answering such longer term questions as:

  • How can new hospital design make the most of advancements in technology and medical devices in order to anticipate natural disasters and better serve patients?
  • How can new hospitals enable more efficient models of testing and inspection for pandemic challenges to safety and cleanliness?
  • Should future hospitals be built with a higher proportion of single/private rooms? And how can hospital design contribute to better sleep hygiene for in-patients?
  • What provision should new hospitals make for key worker / affordable housing?
  • How can sustainable materials, green or natural space (both in, atop and outside hospital buildings), and energy systems be used to ensure the cost-effective and sustainable operation of future hospitals, and reduce the carbon emissions?
  • Can we reduce the overwhelming dominance of the car and ambulance as a means of travelling to and from hospitals? Are there opportunities for fitness and health gains from encouraging other modes of transport?
  • Hospitals tend to be built in utilitarian styles. Is it possible to combine consideration of all practical and clinical constraints with building beautiful so that hospitals could be aesthetic as well as functional buildings?
  • Should local communities and public stakeholders be given more say in the operational decisions of hospitals?

Acceleration Of Leadership Trends

COVID-19 has highlighted or accelerated five profound trends that existed before the pandemic, which are dramatically reshaping healthcare. These trends are:

(1) A more fully networked health-care system:  The hospital of the future increasingly looks to be a network with flexible capacity, connected by a single digital infrastructure: critically ill patients are cared for in ICUs; regular care takes place in connected health hubs in the community; and the at-risk patient population is monitored remotely and more engaged with their health than ever before. Instead of being in one fixed location, the networked hospital of the future will be expected to be

  • more scalable and modular than ever before
  • flexible enough to deliver highly-complex care to large numbers of new patients in ever-changing locations
  • able to provide regular and elective care and counselling to the rest of the population
  • help to ensure that patients receive the same level of care and expertise, regardless of where they live.

Particularly as we find ourselves facing the onset of a second COVID wave, we’ve realized that a networked health-care system, supporting health hubs in the community and patients at home, is needed now more than ever. The networked hospital will support care that is more personal, more accessible, and more dynamic to address health needs that have evolved rapidly with the spread of COVID.

(2) Acceleration of telehealth, hospital at home and virtual care:  Digital technology knits the network together by taking the load off frontline staff, providing low physical contact telehealth care and guidance, and giving various health care and congregate-setting facilities a more critical role in this network. In the near future, remotely guided tele-ICUs within larger hospitals will be connected to mobile facilities and community-based hubs by a single digital infrastructure. Staff in care-coordination centers could better support patient flow and manage resources remotely to remove bottlenecks in the network, including sending clinicians, ICU beds and medical equipment to where they’re most needed, 24/7. 

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(3) Empowering consumers:  The increase in public engagement with our own health and that of our families increases the chance we have of recovering from COVID-19 or of having mild symptoms. This engagement can:

  • increase focus on better eating and exercise
  • reinforce public acceptance of and accountability for social distancing
  • lay bare necessary gaps to be filled in therapeutic counselling for care givers and recipients both
  • promote more constructive dialogue over contentious public-health policy collateral choices such as school closures and business lockdowns.

 (4) Accelerating better natural disaster adaptation and planning:  Rural and inner-city hospitals in the U.S. and other for-profit health-care countries are at great threat of closure and consolidation. In Canada, the need for better preparation and disease treatment information and PPE equipment exchange was poorer than in the previous SARS and H1N1 epidemics.  Urban and rural hospitals that serve low-income communities confront many existential environmental, fiscal and operational pressures:

  • a legacy of over-reliance on centralized, hospital-based, acute care delivery
  • in medically under-served locations, patients have less access to services outside of centralized hospitals, including under-service in primary, preventive, chronic, behavioral health, elder and home care  
  • traditional Fee-for-Service payment formularies tend to direct vital resources toward hospital-based acute care and higher-margin specialty services
  • older, sicker, more-costly patient populations with a higher prevalence of smoking, obesity, addiction, behavioral health issues and chronic disease strain costs and utilization.

(5) Enhancing minimal contact care:  Minimizing physical contact means leveraging digital technology to go about enhancing a safer environment in a primary clinic, hospital and chronic care facility. Interaction with different stakeholders inside a hospital shall be done only if necessary. Surfaces such as pen and paper, curtains and door handles, light switches and elevator buttons, should be used sparingly. The literature discusses multiple modalities and devices for digitally communicating with each other, maintaining adequate notes and records, and reducing hot spot disease transmission surfaces. 

Hospital Innovation COVID Adaptation Observations

As noted in the EthicScan blog The Future: Hospital Systems Post COVID (June 8), hospital systems insiders look to innovations that create a better “new normal” rather than patching operations after adapting to changing COVID realities. Recent insights and observations include:

(a) Mobile units:  Take more hospital care into the community. When COVID-19 broke out in communities with a shortage of medical facilities and health-care staff, public-health authorities in India and Japan demonstrated that they could deploy a mobile mini hospital inside a shipping container. This included an ICU to care for critically-ill patients of COVID-19 and/or rooms with a CT scanner or an MRI or mammography machine to diagnose (in isolation) patients with non-COVID related illnesses. A nurse could drive a mobile healthcare vehicle to your home. Once there, he or she could examine you in person and take advice from a doctor via a video session.

(b) Artificial intelligence (AI): Cloud-based IT solutions already capture and analyze the latest data and research from hospitals around the world – large or small – to gain insights into COVID-19, as well as the complexities of co-morbidities and the efficacy of protocols. Leading providers in certain locations advise applying analytics and AI to support a patient’s multidisciplinary team in making the best treatment decisions for an individual. Think of it like a GPS system in your car, delivering real-time updates to help you find the quickest way home.

(c) Better inventory control: One study shows that a nurse can spend up to 40% of his or her day simply looking for equipment. Vital items like ventilators can be tagged and located using a simple app by anyone who needs them, from nurses to surgeons to department heads. In the hospital of the future, it is critical that nurses and clinicians spend as much time as possible with patients.

(d) Maximize remote procedures for non-COVID patients where possible:  In countries facing a second wave of the virus, health-care authorities know they need to find increasingly innovative ways to care for non-COVID-19 patients without risking infection. In various jurisdictions, there have been large drops in cancer diagnosis and elective surgery for cardiovascular diseases as resources are diverted to manage the COVID outbreak and as patients avoid larger hospitals. One way hospitals could address this is by enabling day surgery to take place in other locations. For example, it could soon be possible and desirable for a patient to have a stent operation in a mobile cath lab in a retail mall closer to home.

(e) Openness to test new devices:  A smart mirror, a toothbrush, sleep monitor and a set of connected weight scales might be able to spot the early indicators of COVID-19, or diabetes, or even detect changes in our mood to indicate stress. This might help our GPs to gain more insight into both our physical and mental health and then provide clinical and behavioural guidance and even empathy from afar. Biometric sensors can already continuously relay vital signs such as our heart rate and respiratory rate back to algorithms that will notify care teams, in case of deterioration. More of these kits may include connected health devices such as blood pressure monitors, pulse oximeters, and heart rate monitors, and even mobile technology devices such as tablets or smart phones.

(f) Focus on wellness:  Wellness mindfulness, rather than numbers of hospital beds, most influences social determinants of health.  We see great disparities in health outcomes within a single metropolitan area. Things such as a lack of adequate housing and healthy food make it almost impossible for many area hospitals to meet their residents’ comprehensive care needs. Wellness promotion rather than “sick care” initiatives must include transportation, housing, nutrition, socialization and education services tailored to individual and group needs and preferences. Many hospitals serving low-income rural and inner-city communities are failing despite a desperate need for appropriate, accessible and affordable healthcare services for local vulnerable populations.

Hospital Operations Management Choices

The literature reveals a number of constructive operations management choices or recommendations:

1. Innovating outpatient management to reduce demand at downstream bottlenecks: To reduce future bottlenecks in emergency departments (EDs) and hospitals, outpatient clinicians should expand their proactive management of patients at high risk of needing acute or inpatient services. This includes those with poorly managed hypertension or diabetes, and triage patients with acute needs to EDs. Doing so now will reduce more serious complications later. This will help reduce potential future spikes in demand on EDs and inpatient beds from non-COVID patients.

2.  Location pooling of specialty services to enhance essential non-COVID inpatient hospital services:  Select hospitals in the United States, Canada, the Netherlands, Denmark, and Australia have applied a version of the logistics strategy known as “location pooling,” – that is, combining demands from multiple locations in order to balance demands across hospitals and other facilities. Rather than each hospital in a region redundantly providing the full suite of essential inpatient non-COVID clinical services, specific services (such as a cancer, transplant, stroke, or trauma center) were concentrated at one or select locations. While implementing this strategy is fraught with challenges, it has been shown to contribute to:

  • (a) better sharing of data on the availability of hospital beds;
  • (b) efficient routing of patients based on their clinical need and the available capacity, and
  • (c) better health outcomes for acute stroke care patients who were taken to designated specialty hospitals rather than the nearest hospital.

3.  Grouping hospitalized Coronavirus patients by their underlying clinical conditions:  To the extent possible, hospitals should practice “cohorted wards”; that is, they should place their COVID-19 patients who have serious underlying health issues (e.g., cardiac conditions) with other patients with the same condition. In each of these “cohorted wards,” redeployed clinical staff from the relevant specialty service, such as cardiology, can provide essential specialty care alongside clinicians addressing patients’ COVID-specific care needs. While such cohorting limits efficiency gains from pooling all COVID-19 patients in one ward, it maintains specialty care for patients who still need it while reducing the additional inpatient capacity strain resulting from patients being dispersed across the hospital. Indeed, research demonstrates that displacing patients from cohorted specialty units is associated with prolonged hospital length of stay and more frequent re-admissions.

4. Discharge patients into post-acute care based on COVID-19 status: Nursing home, rehabilitation hospital, and long-term acute care facility leadership should try to collaborate more fully to establish separate regional, specialized, post-acute care facilities for COVID-19 and non-COVID patients. Sending patients to specialized post-acute care facilities based on their COVID-19 status will:

  • (a) facilitate discharge planning,
  • (b) improve patient flow out of the hospital for COVID-19 and non-COVID patients alike;
  • (c) relieve strain at ED and hospital bottlenecks while maintaining care quality,
  • (d) where post-acute care facilities for COVID-19 patients exist, this will preserve post-acute care capacity for those recovering from non-COVID illnesses, while lowering their risk of becoming infected.

Challenges to this model choice include ensuring timely access to COVID-19 testing and rapid test results in order to guide appropriate patient routing. To prevent discharge delays due to testing constraints, hospitals need to implement rapid tests more widely, and post-acute care facilities should designate quarantine areas for patients to receive care while awaiting results.

5. Hospital decision-making needs to embrace a philosophy that consumers are more in control: The public is asking for transparency, digital empowerment, the power to keep themselves well, and affordability. In some jurisdictions, people aren’t getting treated, they’re having heart attacks and strokes and diabetic emergencies at home. One in four Americans in the past year delayed care or forwent it entirely because they couldn’t afford it. This pandemic crisis has sharpened the need for hospitals to focus on making these empowerment and equity goals much more responsive and available to the people they’re meant to serve.

6. Hospital care should be anywhere and everywhere:  Virtual appointments and telemedicine will play a much bigger role in future hospital care. A recent study has linked higher levels of telehealth with lower mortality rates at institutions. “The acceleration of the medical home being the patient’s home—this crisis has pushed us further down that path than ever before,” said one of the study authors, adding that consumers will consequently think about health-care choice more expansively.

7. Reimburse prevention and outcomes, not treatment: The pandemic has brought with it mental illness, chronic diseases, and stress for patients, staff and front-line providers as well as specific groups like school-age children and business owners. At the same time, business shutdowns mean that government revenues are shrinking and hospitals will likely not be getting the revenue that is so essential to meet their budgets, today or (even more so) tomorrow. There needs to be a fundamental multi-stakeholder public review of hospital funding tied to prevention and health-care outcomes as much as treatment and in-patient services.

8. Hospitals focus on acute care:  Hospitals aren’t about to disappear. However, they will need to shift their focus to the highest-acuity patients. This is where leadership will continue to move to health systems, which, by their nature, leverage multiple model choices of patient care. From live to virtual care, a health system that meets patients where they are can more effectively care for everyone while controlling hospital costs and stewarding the health of health-care worker staff.

Conclusion

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There is much new data from many jurisdictions being published on optimal hospital adaptation to COVID. The public has a right to demand a multi-stakeholder re-visioning of hospital care management and operations as part of a more affordable, accessible, and sustainable future for health care.

Further Resources

Philips – What will the hospital of the future look like in a post-COVID world?
https://www.philips.com/a-w/about/news/archive/blogs/innovation-matters/2020/20200707-what-will-the-hospital-of-the-future-look-like-in-a-post-covid-19-world.html

Modern Healthcare – The Future of Hospitals in Post-COVID America (Part 2): The Policy Response:
https://www.modernhealthcare.com/hospitals/future-hospitals-post-covid-america-part-2-policy-response

EthicScan Blog – The Future: Hospital Systems Post-COVID
https://ethicscan.ca/blog/2020/06/08/the-future-hospital-systems-post-covid/

Harvard Business Review – How Hospitals Can Meet the Needs of Non-Covid Patients During the Pandemic:
https://hbr.org/2020/07/how-hospitals-can-meet-the-needs-of-non-covid-patients-during-the-pandemic

Entrepreneur – Contactless and Digitized – The Future of Hospitals in the Times of COVID-19:
https://www.entrepreneur.com/article/353147

Policy Exchange – Call for evidence: Building hospitals in the post-Covid era:
https://policyexchange.org.uk/publication/call-for-evidence-building-hospitals-in-the-post-covid-era/

Fortune.com – 4 ways the coronavirus pandemic will change hospitals:
https://fortune.com/2020/07/09/coronavirus-hospitals-changes-impact-medicine-health-care-covid-19/

Vituity – Embracing the COVID-19 Disruption:
https://www.vituity.com/blog/defining-future-of-hospitals/

David Nitkin
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