In Italy all citizens, both Italian and foreign, are covered by the National Health Servic which, through public emergency aid, takes care of all the people who come or are brought to the Emergency First Aid Departments. Family or public doctor, which services are usually considered a right of the citizen, is also paid by the State.
In our country there are no totally private hospitals or hospitals operating without the use of public funds but there are "Nursing Homes" also called "Clinics" (See the section "Medical Surgical Clinics"), which operating privately in total offer a range of services definitely reduced compared to that offered by state hospitals. The management of a state hospital is not in any way equivalent to the management of a private medical structure in the conditions of a free market, therefore, often it is not considered important by state hospitals that the medical structure should move towards efficiency and continuous improvement of its activities. There only exists the concept of the "economic crutch" coming from public funds.
In addition to public funding, there are two other important differences between the "Clinics" and hospitals to be remembered at this point, which are the number of services offered and the number of managed beds, usually clinics have a limited amount of both elements compared to the hospitals.
Abandoning the concept of the clinic (which will be taken up in other sections) we would like to give further details on the "management" of Italian public hospitals.
In Italy, a hospital, as a rule, is maintained by: Bodies of the State (Regions and networks of hospitals), religious congregation (accredited by the National Health Service), Private Party (accredited by the National Health Service)..
Of the three subjects cited above the worst results are achieved by the hospitals run by religious congregations operating more for "grace received" than according to economic criteria. In such structures the costs have always been real "refunds at the bottom of the list" and there were no managerial roles with the ability to take charge of the situation and bring the structure to the way of management especially in the moment when the imposing economic funds were exhausted. Religious congregations have always been hostile to opening to the external world and prevented, by virtue of this, the involvement of experienced managers. This has generated a nasty organizational and economic situation in which these structures find themselves nowadays.
The public subjects, in most cases, has managed its structures by way of regions. The regions in turn appointed their general managers of hospitals not according to the criteria of the ability of individuals but according to political issues. General managers were then predestinated to "respect" a "political appointment" rather than follow a professional task. The management of the structure proceeded by sheer inertia and not according to the strict guidelines and this obviously has created a serious impact on the performance of these structures..
The private entities dedicated the management of its structures to the efficient staff which generated very important revenues through public funding. These subjects represent the "fake entrepreneurs" or those who do not operate in a regime of free market and not seek to increase the level of effectiveness of the services they offer but just search ways to get more funding. These subjects, due to the absence of rationalization and control of the Italian health system, have accumulated funds which surmount limits of any entrepreneur operating in the field of healthcare services.
The Mission of “Top Physio Engineering” for Hospitals is to offer a comprehensive renovation which is based on the analysis and improvement of four different areas. These areas over the years has been an obstacle to the development of these structures:
physical structure of the architectural complex
The physical structure of the architectural complex, technology, organization
Let's start with a little bit of history. Over the years the hospital has always been structurally conceived as a "dormitory" or, later, as "pavilion", and in both cases the "structure type" that was to provide huge common areas where to place the patient in waiting that the primary physician (whose talent was directly proportional to the number of beds managed) and his team, were coming on usual medical visits, almost like an area designed for the needs of physician practices and not of individual patients. Over time, these spaces have been reduced, the number of people to share a hospital room is drastically decreased but to the present day the true goal to have room for each individual patient have not yet been reached.
In the worst moment in the life of the individual when one is ill we force him to share a room and feel uncomfortable with strangers. A society that professes privacy at 360 °, is unable to give the patient a dedicated space of the right size in order to substantially improve the conditions of his hospital stay.
Our solution is to give the patient his space, 12.5 square meters entirely dedicated to him, including personal toilet for the disabled.
Let’s analyze a second issue related to the architectural complex: spaces dedicated to the emergency departments. For instance, every year in the hospitals of Rome are registered a little less than 1 million emergency visits (which means that 14% of the population of Rome and the province access to the emergency services averagely once a year). The current dimensions of the "First Aid Departments" are on average too small to respond effectively and efficiently to the needs of citizens. In the current situation the First Aid Departments can barely deal with codes of extra urgency. Practically everything is done to save lives but nobody tries to manage the patient which is not necessitate an urgent help. An example is a patient who comes to the emergency department with a fractured femur (such trauma is very common in our society today). Once in the emergency room the patient, since it does not risk its life, doesn’t undergo an immediate surgery for stabilization of the femur but is placed in the ward waiting for the hospital staff to be ready to provide the service. This delay creates a longer permanence of the patient in the hospital (overcrowding of the rooms), worsening of the patient’s clinical picture, an extension of healthcare services to be provided to the patient due to the aggravation of the clinical situation (higher spending), in brief medical care is not optimal, space insufficient, costs soared.
Several times in history, by way of different methods and ways, an attempt was made to reduce the number of emergency visits by managing the patient through general practitioners or directing the patient to other structures. No way so far undertaken has brought neither significant results nor acceptable implementation costs.
Our solution is to create an emergency department that, after a thorough overall diagnostic classification of the patient would be capable to:
- discharge the patient, in case of a non surgical pathology, in order to direct the latter in a post acute care medical facility (not to be confused with the post-acute rehabilitation facilities), low-cost and appropriate to his needs, that can keep the patient under proper medical observation and proceed accordingly to the represented problem;
- perform the surgery, point to reduce hospitalization period and organize an appropriate post- acute care for the patient.
In summary: In-depth and immediate analysis which provides a clear possibility of choice and determines a flexible structure. The myocardial and pneumonia patients should not be managed in the same way as they require different treatment and there is no need to put them both to the emergency ward in awaiting.
Of course, to do all this is necessary to::
administer the management of the hospital not to a physician, which is predestined to providing a healthcare services, but to a concrete entrepreneur conscious of the reality that he manages;
implement rationalization of the spaces in order to create an emergency area equal at least to 30% of the total surface area of the structure;
provide an organization in which the structure revolves around the patient's needs and not those of the physician;
dedicate the best specialists not to the departments in organic but to the emergency areas or rather where it is most needed;
assess the human resources and the whole structure according to a logic of quality and not quantity of services provided to the patient;
individualize “surgical specialties” for each hospital on the territory of the city / province so that each of these hospitals can manage in the best way patients with that particular pathology;
be provided with at least one of the ICU, CCU and all surgical specialties available H 24;
introduce avant-garde technologies in support of professionals.
But if we devote 12.5 square meters for each patient, if we amplify the First Aid Areas, if we invest in technology and if we change the organization in the way that we respect the now existing spaces and containing the costs?
If we intervene immediately and in the best way with the patient (using appropriate technologies and available specialists) we cure him more quickly and with better results and if we cure more quickly his hospital stay is reduced, if hospitalization is reduced serve fewer beds , if we need less beds with the existing space we can create single rooms for the patients. Also, if we do not need to have departments because all departments which currently serve are WHERE they are needed, namely in the emergency area, we have more space to expand the emergency area. In summary better service, rationalized spaces, reduced or better invested spending on professionals and technologies.
To conclude this session is good to do a summary of the characteristics of the structures previously mentioned and what is our idea of them. The hospital must provide immediate complete care of serious and/or surgical pathologies, must then refer the patient to either post acute care medical facility or a post acute rehabilitation facility. The post acute care medical facility must provide to the patient accommodation, meals and constant medical "observation". The post acute rehabilitation facility must provide meals, accommodation and rehabilitation. These structures do not have to provide more. Slender and low-cost structures appropriate to the specific needs of patients.
The economic sustainability
One cannot but analyze the economic situation of hospitals in the middle of the XXI century.
As is well known in the early nineties, to contain the waste in the healthcare field was introduced a system already experienced in America ten years ago and called Diagnosis Related Group (DRG). The DRG was and still is based on the information supplied in the hospital discharge summary of the patient, establishing the amount of the financing granted by the region to hospitals. The National Health Service provides funding based on the delivered hospital services, rewarding the medical performance according to predetermined rates according to DRG.
The summarized mechanism is interesting and undoubtedly logical but today cannot find a completely adequate implementation.
The funding to the present day provided by the National Health Service to public hospitals is based on rates of spending of two decades ago. In brief, the state reimburses of hospital expenses on the interventions are nowadays as they were listed 20 years ago when there were no right technologies, the preoperative phase lasted many days, when the hospitalization period was extremely long and when the intervention approach was totally different from what it is today. In short, a failure to update the DRG rates according to the real situation. Given the speed of technological innovation and the dynamics of the provision of medical care, it is impossible to use this system effectively without an update at least every six months..
Hospitals follow a criterion of economic sustainability without ever having really achieved this sustainability.
All the above is undoubtedly the result of a management always "assigned" and never carried in the first person and always without assumption of any kind of responsibility..
Regions should demand funds equal to their needs, the Ministry of Health to serve as a control body for these requirements and the Ministry of Economy should disburse money to regions according to the needs controlled by the Ministry of Health..
But what happens in reality?
It happens that the Ministry of Health does not control spending asserting that it is an "impossible thing" and that the Regions, through the requirements, control the money that comes into their pockets from the Ministry of Economy. For its part, the Ministry of Economy, having exorbitant health care spending and given the complete lack of cooperation of the other involved agents, cuts all costs without any logical or human criterion.
Our truth is that the Ministry of Health can and must control public spending through restructuring of the cost of the service according to DRG but so far, no Ministry of Health that have succeeded over the years, has pondered on this. Analyze and update the cost of a single performance of the DRG is the only possible way to assume responsibility. No one chooses to lead a healthy change.
Our proposal is a reversal of the total current situation. The hospital must be managed by professional managers who know the importance of quality of service provided and of economic sustainability, moreover the structure and organization of the hospital cannot be concentrated on the figure of physician but should instead be concentrated on the patient and their needs. Only if one adopts this philosophy can really make a change.
Only if one adopts this philosophy can really make a change. The quality of service; Cure of the patient; Economic sustainability. Our choice. Our challenge. Our path.