Hopkins revamping hospital Venerable institution focuses on service to win market share

Disney trains security guards

Profits have grown from $1 million in '92 to $20 million in '95

June 16, 1996|By Diana K. Sugg | Diana K. Sugg,SUN STAFF

Under intense pressure from market forces, Johns Hopkins Hospital is in the midst of a huge overhaul, reshaping everything from the way the staff greets patients to how doctors handle cases.

The strategies are expected to save $25 million in the next fiscal year alone. The sweeping changes will affect every worker, nurse and physician, and many of them are being asked to help redesign their own workplace. Patients have shorter stays. Their records are being computerized. A robot will help count pills in the pharmacy.

Hospitals across the country are making similar moves. They must, if they want to survive in an environment where powerful managed care companies can demand lower prices. But academic medical centers such as Hopkins are taking more drastic steps, because their extra functions make them 10 percent to 15 percent more costly. They train new physicians, do research and care for the poor.

Hopkins is steeped in those missions. For generations, its mind-set, and the old health care environment, allowed it to ignore the issue of cost. But the revolution rocking the U.S. health system has altered that reality.

"Almost every facet of the institution has to change in response to managed care," said Dr. James A. Block, the hospital's president and chief executive officer, who has set many of the initiatives in motion. "We see this as a fundamental shift of what we're all about. How can we do what we do better, and in an affordable way?"

Some of the key reforms:

Blueprints for 115 diagnoses lay out the care patients will receive, including tests, medicines, and every detail from when they should first get out of bed after surgery, to day of discharge. About 55 percent of patients admitted to Hopkins are put on one of these outlines, called "critical pathways." Roughly 90 of the 115 guidelines are in effect.

A restructuring of the duties assigned to hundreds of registered nurses, aides and other support staff will be phased in starting next month. Registered nurses will no longer step in to make beds or leave the unit to get supplies. Any job cuts mostly will come from attrition, and there will not be any "substantial layoffs," Block said. The new positions will complement the way care has been redesigned by several committees, with the patient as the focus.

A fresh emphasis on customer service that requires security guards -- and eventually all employees -- to be schooled in friendliness by the Ritz-Carlton, Sheraton or Disney.

Efforts are under way to attract patients -- through additional contracts with health maintenance organizations and local family physicians, and through a "Hopkins USA" project to draw people from around the country.

Hopkins is also working to serve more of the Medicaid population, with experiments set up to treat those with AIDS, substance abuse and severe mental illnesses.

New outpatient sites

To strengthen their feeder system, hospital officials are looking at sites in Howard County and White Marsh to duplicate their outpatient site at the Greenspring complex.

To find new ways to treat people in less expensive settings, Hopkins will begin construction next year of a nearby hotel, where recovering patients who need limited medical oversight can stay -- for less money -- under the eye of a nurse.

The changes raise the potential that in the rush to cut costs, quality will be lost.

But like the University of Maryland Medical Center and others across the country, Hopkins is setting up ways to track how their changes affect patients.

On the most basic of measures -- mortality -- Hopkins has so far found no difference. Eventually, the "outcomes" analysis will include more sophisticated measures, such as how soon the patient can go grocery shopping and return to work.

Meanwhile, as the changes at Hopkins go into full gear over the next several months, it will be difficult to assess the full impact.

But turmoil and anxiety are expected. A nurse at Johns Hopkins Bayview Medical Center, where many nursing jobs have already been restructured, said some nurses were "devastated" by different assignments and worried about being responsible for the actions of lower-level support staff.

"The atmosphere is very stressful," said Gail Marshall, a charge nurse who has worked at Bayview for six years. But she also has been involved in planning and said she thinks patient care is better.

Patient volume increased

Objective indicators show Hopkins' position has improved over the past three to four years.

The 1,000-bed hospital has gained market share, and patient volume has increased by about 10 percent, or about 2,600 more patient discharges, between 1992 and this year.

Patient satisfaction levels remain high, according to in-hospital surveys by Hopkins. The combination of more patients and the )) retooling has boosted the hospital's profits to the highest in its history.

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