Hospital Self-Diagnosis: Change, or Perish : St. John’s saga shows why bed-centered hospitals may be dinosaurs
It speaks volumes about hospital care today to say that 100 of the 300 patients at St. John’s Hospital and Medical Center in Santa Monica were sent home when the Jan. 17 earthquake forced the venerable institution to shut both of its in-patient wings. Since then, the hospital’s administrators have been asking themselves: Why were the patients there in the first place if they could go home? It is a good question, one that goes to the heart of the national debate over health care reform.
The quake puts hospitals in Southern California in a unique position to lead the nation in designing the hospital of the 21st Century. New medical and information technologies, forced by the radically changed economics of medicine, have in certain ways made even the most modern hospitals obsolete. St. John’s will rebuild, but the new hospital will certainly be very different, and smaller.
Long before the quake, hospitals here and across the country were struggling with a harsh fact of life: They are losing their traditional function as the main center of medical care.
With most surgery now done on an outpatient basis, occupancy rates have plunged. According to the California Assn. of Hospitals and Health Systems, 18 hospitals in the state closed last year and the number of beds staffed for patients has dropped by about 40% in the last decade; still, most hospitals are “over-bedded” and operate in the red. One shuttered wing of the California Medical Center downtown is regularly rented out to movie companies that need a hospital setting. Apparently there is sometimes more profit in make-believe doctors, nurses and patients than real ones.
All major hospitals are gearing up to compete under the new “managed care” paradigm that is forcing tight controls on patient spending. The hospitals themselves are going into the managed-care business. Cedars-Sinai Medical Center and Huntington Memorial Hospital, for example, are joining with doctor groups to form their own health maintenance organizations. Mergers and consolidations are the order of the day. Whatever emerges from the tortured debate on health reform in Washington is likely to hasten these trends. It all means more emphasis on primary care, the family doctor, and less on specialists and hospitals. St. John’s has furloughed 1,700 of its 2,050 employees, and many will never be rehired.
All this has major implications for building or rebuilding a hospital today. Clearly fewer inpatient beds are needed. Technology will dictate architecture and organization. For example, Dr. Thomas M. Heric, senior vice president at St. John’s, talks about sending surgery patients home quickly and monitoring them by video.
When it reopens, St. John’s, licensed for 501 beds, will probably have only 150. “For us to rebuild as a 500-bed hospital would be a major mistake,” said its president, Sister Marie Madeleine Shonka, adding that she expected the lost rooms to be replaced by a separate ambulatory care center. And its longtime rival four blocks away, the Santa Monica Hospital Medical Center, which also suffered quake damage and has excess capacity, has put out a friendly hand to see if cooperation can reduce costs and duplication of services.
A danger in all this is that the quest for efficiency will come at the expense of the community service and the caring traditionally provided by hospitals. For all its movie-celebrity aura, the 51-year-old St. John’s--operated by a Kansas-based Roman Catholic order, the Sisters of Charity of Leavenworth--has an admirable history of charity. For example, it provides free surgery, obstetric care and laboratory work for the poor and homeless clients of the Venice Family Clinic.
It makes more sense to shape the future than fight it, to embrace economic realities than battle them.
Waste and inefficiency must be squeezed out and medicine compelled to obey the laws of economics. But as the hospitals move ahead, let not efficiency overwhelm community convenience and service, let not the need for black ink blot out compassion and charity. Hospitals in the future can accommodate harsh, new financial realities yet remain true to their noble origins.
