Tendencias en la alianza entre hospitales y otras organizaciones de salud

In my opinion, the hospital sector of the Philippine healthcare system has two serious concerns. The first is about the continuing rise in the cost of delivering and expanding healthcare to the end-users through the hospitals. The second is about the working hospital staff—its supply shortage and the urgent need for skills upgrading. These two concerns must be addressed always in relation to the internal stability of the hospital as a viable organization and in relation to the external social responsibility of the hospital in the promotion of health—as the primary, the biggest, and the most visible provider of healthcare goods and services to the population.
All efforts to partner with “other allied health organizations” can be made more meaningful if these two concerns — and the sets of issues that they raise — are addressed directly. Only then can the hospital continue to develop—to break old barriers and create new paradigms, as this convention puts it — in response to factors such as scientific and medical breakthroughs, changing health care needs and emerging technologies.
Some recent news items have convinced me further that the main concerns I am talking about are more or less the “global trends,” that is, as true here in the Philippines as they are in other parts of the world, in developed as well as in developing countries. In the United States, for instance, a federal advisory panel has declared that, because of the rising cost of financing hospital care, “the American health care system is confronting a crisis. . . [and is] incapable of meeting the present, let alone the future, needs of the American public.» The panel reports that the number of Americans that do not have access to hospitals now stands at about 15 percent of the American population, or 41.2 million. It has proposed many demonstration projects to optimize cost utilization in hospitals, such as a «paperless health care system» and a hospital dispersal program by beefing up selected community health centers with sophisticated equipment.
And last month, the American Journal of American Medical Association published a study that showed a direct correlation between the workloads of hospital nurses and patient survival. For every additional patient a nurse was assigned to care for, the study said, the odds of a patient’s dying within a month of hospital admission rose seven percent. This finding is alarming in light of the current nursing shortage experienced across the United States. It is more alarming still, the study warned, because of the “the vicious circle” that this shortage engenders — the more understaffed hospitals are, the more demoralized nurses become, the fewer recruits join their ranks, the worse nursing shortages grow, and the more understaffed hospitals become, and so on and so forth. Of course in the Philippines, the question of hospital staff—its size and quality—is aggravated by the fact the country is a net exporter of nurses to many countries.
Not only has running a hospital become increasingly more costly, building new hospitals to meet increasing demand for patient cure and care has become a very high-risk proposition. In the early 90’s the cost to construct a tertiary hospital in the country was about one million pesos per bed. In comparison, the newly-built 250-bed Asian Hospital in Alabang has cost about four billion pesos, or 16 million pesos per bed! If this is any indication, then we can only shudder at the thought of what the cost of the new Medical City under construction in the Meralco compound and the St. Luke’s Hospital project at Fort Bonifacio may be. Now these may be extreme examples and the comparison may be invidious; nonetheless they do give us a more or less clear picture of the escalation in size of investment to build hospitals, not only tertiary but primary and secondary hospitals as well.
Now the more problematic part of building hospitals comes after the fact. According to a WHO study, once built, hospitals, both private and public, are extremely difficult to close down — for various reasons, the most compelling of which is the fact that a hospital is a tremendously expensive health resource, a complex combination of human and other resources.
In the public sector, hospitals do have high political profiles. Budgets may be drastically cut, the quality of services may deteriorate, the physical facilities may sink into decrepitude, but closing them down is simply not an available option. As the WHO puts it, “symbolically, hospitals are viewed by the public as the main manifestation of the health care system.”
In the private sector, hospitals are kept financially viable and the quality of care maintained by increasing hospital charges and by means of high financing. In the end, this means excluding more and more people, making hospital operations a dangerous exercise in financial brinkmanship, and, most unfortunate, taking the private hospitals further and further away from its mission of social responsibility.
I have prefaced my discussion topic “the trends in partnership between hospitals and other allied organizations” lengthily thus, expressly in order to stress that that I am keeping myself away from speculative ground—that is, from the structural question of what the hospitals of the future would be like under various assumptions of disease patterns, hospital organization and new technology. I am loath to speculate on this because this question is properly within the purview of healthcare policy.
For this occasion I am taking the present structure of the hospital sector as a given and am confining myself to partnering trends and opportunities that directly bear on the “disturbing global trends” in the hospital sector—cost escalation and hospital staff shortage—and on the social mission of hospitals.
That said, I will now describe some hospital-allied health organization partnering opportunities that have bright possibilities and strong impact on hospital operations. The ideas are not new; in fact, they have been percolating for some time now. The challenge to hospitals and those that manage them is execution—how best to establish and operationalize external linkages and networking to address the internal and external concerns of hospitals. By internal, we mean their operating efficiency, organizational effectiveness and financial viability. And by external, we mean the capability of the hospitals to meet their social responsibility.
The possible partnerships related to the internal concerns of the hospitals can take the following forms:
Joint purchasing –
This calls for the hospitals to create a purchasing organization or consortium that will permit them to leverage volume purchases for better prices. (The Philippine Hospital Association tried this once. We do not exactly know what has come out of it, but it will certainly add to our learnings if the experience and knowledge gained from this attempt are shared.)
PhilHealth electronic linkage for claims processing –
While PhilHealth is currently developing its information system, the hospitals can work together with their partners to design a system that allows for seamless computer connectivity between PhilHealth and the individual hospitals. This will make possible, among other things, faster PhilHealth collections. Smaller hospitals that cannot afford full computerization can group themselves together and designate one hospital or any other entity as the point of PhilHealth electronic connection.
The same approach can be adopted for claims with HMOs and other private institutions.
Tie up with third-party organization to manage inventory of medicines and supplies –
A good example of this is the design of the hospital pharmacy operating systems and the management of the hospital pharmacy. Store management expertise and skills are usually not part of the set of hospital core competencies. We believe that this is the main reason behind the mess created by some hospital pharmacies on hospital operations.
Tie up with other hospitals and academe to define and document best practices in various hospital departments –
The aim is to build a model of good practice, set standards and benchmarks, and develop implementation methodologies to achieve operating efficiencies. This is based on the reasonable assumption that quality assurance activities and continuing professional development lead to improved quality of hospital care.
Essentially, this all boils down to a systematic total cost analysis and management of hospital efficiency. Hospital managers can therefore make informed—and better—decisions on basic issues related to cost optimization and resource allocation: what are main areas of expenditure? how to select the best combination of resources? what resources are underutilized or wasted? what are the services than can be outsourced—pharmacy, laboratories, building maintenance? is the hospital running at full capacity?
Tie up with academe or other specialized organizations for the training and development of hospital staff –
Recent evidence suggests that there is a strong relationship between organizational culture and quality of care. In particular, nurses regard highly hospitals that are organizationally stable, that is, hospitals that offer a good environment in which to practice and develop nursing as a profession and hospitals where good relationship between doctors and nurses exists. Organizational factors such as patient-centered culture
Providing nurses with well-designed training and development programs can increase their professional job satisfaction. The more successful programs focus on the building of a patient-centered culture, strong medical and nursing leadership, effective collaboration, and an open approach to problem solving. Not only do programs of this nature increase the morale of the nursing staff, they also serve as “magnets” that attract new nurses.
Holding job fairs to attract new nursing graduates is a good strategy to strengthen the hospital staff; but making these nurses love working in the hospitals is the real, and the more difficult, challenge.
On the other hand, the partnerships related to the external concerns of hospitals can be as follows:
Tie up with the Department of Health or Local Government Unit health offices to implement specific health programs. Hospitals can act as DOTS centers for the tuberculosis control program. (Incidentally, our DOTS center at Unilab has this kind of existing tie-up with the government.) The hospitals can also act as immunization centers on certain designated periods. The hospitals can assume specific responsibilities in responding to disaster and health crisis situations.
Tie up with the government or with other private entities to dispose of hospital waste according to good environment standards.
I understand that some hospitals in the Visayas (led by Cebu Doctors) have already formed a group to address the problem of waste management and disposal.
Increase access to healthcare through closer training collaboration between tertiary and lower level hospitals.
Tertiary level hospitals can “adopt” primary hospitals (public or private) to help upgrade the latter’s technical skills. This should mitigate somewhat the criticisms against the concentration of care and facilities in big hospitals and the consequent unavailability of the services of tertiary level hospitals to populations away from key urban centers.
There are many other partnering opportunities that I have not mentioned today, but the foregoing comprise the set of opportunities that have already been explored before. I think that it is time to revisit and reevaluate these opportunities. I think the task now is for the hospitals and their potential partners to sit down in earnest to make these partnering opportunities work as practical and executable approaches. Ultimately the nature and extent of partnering to be pursued are dependent on the hospitals, on their willingness and readiness to enter into partnerships, and on their priorities as providers of health care.
Let me conclude by saying that we in the pharmaceutical industry empathize with the hospitals and understand the predicament they are in. I think that, since we both deal in a social good that is health, we both have to struggle constantly to strike a balance between financial viability and social responsibility. Unilab has been able to achieve both ends by always seeking alternatives and partners.

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