Daily Observer
There
seems to be considerable confusion in the public mind as to who runs the
hospitals.
Most
are public or private non-profit institutions governed by a board of
trustees. The purpose of the board of
trustees is to see that the hospital is run as efficiently as possible for the
care of the patient. Since perfect
patient care is an unachievable goal, the board must aim for optimal care.
The
board usually regards its function as establishing policy, which will, it hopes
be carried out by hospital management, directed by the administrator.
Trustees
can be tightly knit self-perpetuating bodies constituted to obey a set of
by-laws which describe the manner in which vacancies are filled and so forth.
Hospitals
usually serve wide segments of the communities in which they are established,
so that they, and their governing trustees wield
crucial power. However, if a hospital is
poorly governed, the members of the community may find it difficult to replace
the trustees with a new governing body.
More often than not, the trustees form a hospital association, which can
be joined by any member of the community willing to pay the appropriate
dues. Members then vote periodically for
new trustees.
However,
the average member of the community, unless he has had personal experience as
an employee or patient in the hospital, can poorly judge the efficacy of the
hospital environment.
Intrinsic,
therefore to the structuring of the hospital corporation, is an imbalance of
power, where the trustees are virtually unopposed.
To
determine the efficacy of hospitals, the Joint Commission of Association of
Hospitals (JACH) an amalgam of AMA and AHA authority as well as state
authorities, periodically conduct inspection tours.
These
can be predicted usually by the rate at which hallways are cleaned, bulbs
replaced and walls painted. The
inspection tourists walk through the halls, on pilgrimages conducted by the
very people they are inspecting, the host administration and board of trustees.
They
pay particular attention to records, and the required paperwork paraphernalia
that is supposed to prove that all is functioning according to Hoyle.
They
have vast powers, and hospitals that fail accreditation reviews are in danger
of having third party payments cut-off.
On the other hand, accreditation by inspection committees is evidence
that the board of trustees has been effective and that the hospital is properly
run.
The
problem is that all of these maneuvers are on or more steps removed from the
immediate needs of the individual patient.
Patients
are sent to hospitals by their physicians.
The medical care of the patient is the responsibility of the
doctor. It would logically follow, that
the ecology of the hospital to which the patient is being admitted should
normally be part of the medical care.
Thus, if the hospital ecology is bad, or if inefficiencies abound, no
matter how neatly the records are being kept, the medical care of the physician
prescribes can easily be nullified.
Thus,
the problem that exists is how to make the board of trustees aware of the
infinitude of details of patient care.
There are only two groups, (aside from the patient himself who is not
always unbiased,) who can judge whether or not the intimate details of patient care
are properly attended; management, including the nurses, who are employees of
management; and the doctors who visit their patients daily, examine them, and
collate the various reports from the laboratory, x-ray, pharmacy, and
consultant physicians.
For
management to bring to the attention of the board of trustees errors that occur
under their jurisdiction would be self-indictment, and
management is not prone to assume this burden.
Management,
which included the administration and the nursing department, usually attend to
all individual improprieties that are brought to their attention via direct
complaints, or incident reports, but they do not set a general policy that
would provide an overriding correction to the system that caused the errors in
the first place.
They
patch the dike. The board of trustees is
supposed to set policy. However, they
cannot do this if they are kept in ignorance.
Boards generally do not send their own inspection teams to generate information
of this sort.
Thus
the physicians attending patients in the hospital are the only independent
group who can provide an almost equal and opposite balance to the unlimited
power of the board. They physicians have
both the expertise and independence that, when combined with daily surveillance,
are in the best position to judge the ecology of the hospital upon which much
of their efficiency as doctors depends.
It
is the physicians who can best judge the quality of tools and instruments with
which they must work. If a board sets a
salary scale too low for efficiency, the physician must contend himself with
less than adequate help. Yet in the
overall management of patient care it is the physician most often held
liable. This inequality is being redressed
to some extent now by the courts who recognize a
responsibility on the part of trustees, who also must face the unpleasant
prospect of malpractice suits.
Thus,
it would seem that the medical staff could best serve the hospital by bringing
directly to the board of directors, in an organized fashion, problems, the
correction of which would be vital for patient care.
Currently,
physicians serve on the board of directors and on joint conference committees,
where their influence is diluted.
Perhaps
hospitals and communities in general would be better served if physicians
removed themselves from the governing bodies of hospitals and instead formed a
tightly knit group who would “keep book” on the hospital, and in monthly
memoranda to the administration and board, detail problems that should be
attended to. These memoranda would then
become part of the official record to be shown to the inspection committees, as
well as the response of the trustees to the complaints.
An
arrangement of this sort would be in the constitutional spirit of separate and
opposing powers that has in the past served the country well.
The
government is now forcing physicians to police themselves with regard to
patient care. The institutions in which
the patients are hospitalized provide important services which cannot be
excluded from the physician’s responsibility, and thus should fall under the
same surveillance.