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Where Does Hospital Care Begin and End?

by Scott MacStravic

Fred Fortin’s posting on this subject on Jan 28 described how Leland Kaiser at the Center for Health Design described the “place” challenges facing hospitals as centers for transformation and healing. But it is an unfortunate reality of hospitals and the Center, itself, that they are both overly concerned about hospitals as places rather than things. Clearly, when any organization defines its mission and vision, it makes sense for it to indicate what it aims for, but also what it does not aim for, both hospitals and the Center seem concerned with health, not merely sickness.

The Center, for example, is clearly concerned with how the design of hospitals, as workplaces, affects the health of those who work there, in addition to the effect of place factors on the health of those treated there. It has published a report “The Role of the Physical and Social Environment in Promoting Health, Safety, and Effectiveness in the Healthcare Workplace”, for example. Another promoted a broad view of health including the total environment. “T. Schettler “Toward an Ecological View of Health” Kaiser, himself, has argued that hospitals must concern themselves with what patients’ do and experience before they are admitted to, and after they are discharged from the hospital.

While this concern may focus solely on the extent to which the “before” experience best prepares patients for their sickness care, and the “after” follow-up enables them to optimize their recovery, there are certainly added elements that could be included in follow-up care. Why shouldn’t hospitals concern themselves with preventing repeats of the same causes that led to the patient’s admission in the first place? It would certainly be in the best interests of that patient, and the community at large, if repetitions were avoided, or at least minimized.

When the cause of the original admission, as so many are, was an existing chronic condition, there are proven methods of reducing future crises, complications, and worsening of such conditions, for example, though the patients’ own physicians would have to be involved in this as well. Fortunately, a great number of hospitals own or have strong affiliations with primary physicians who can handle what they do best in preventing repetitions, while hospitals can focus on what they do best.

When the cause of the original admission is an acute illness or injury, hospitals also have the opportunity, with the help of patients’ physicians (if any) and patients, themselves, to discover what led to the illness and injury, and prevent repetitions of that. They could then use the same information about populations of patients to reduce the incidence of acute and chronic disease in the community, in a true, comprehensive, and proactive mission of protecting and improving health, not merely the reactive mission of treating disease.

Arguably, the Center for Health Design — despite the use of the word “health”, rather than “hospital”, “healthcare organization” (it has published papers on physician practices and long-term care organizations, as well), or even “healthcare” – may logically limit itself to “places”, and to healthcare places, at that. But hospitals, despite predictions of continuously growing sickness care demand, are only part of the problem, not part of the solution, when they restrict themselves to sickness care.

Fortunately, dozens, if not hundreds, perhaps even thousands of them (I know of no count made by their trade associations) are already engaged in proactive health efforts. These may be limited flu shot campaigns, health screening fairs, fitness center operations, executive health programs, etc. They may be workforce health management efforts aimed at their own employees, at the workforces of local employers, or in the case of Mayo Clinic, for example, the workforces of large employers throughout the country.

Hospitals deal with patients, plus family members, friends, and co-workers who visit patients, at arguably one of the best “teaching moments” that anyone concerned with promoting and maintaining health ever enjoys – a time when they are seriously ill, in most cases. This gives them a unique opportunity in their follow-up care, and in their before and during contacts, to learn about the causes of their patients’ sickness, and to approa