Handoyo M. 2018
Abstract
Background: Most of the world’s population does not have access to surgical care, and access is inequitably distributed. As the global health community continues to support the advancement of universal health coverage, the near absence of access in many low-income and middle-income countries represents a crisis. We believe “super” efficient hospital business model can improve patient access to surgery care.
Methods: We reviewed micro-hospital business model using critical literature review. We built a new model that most visible to be implemented that we call “nano-hospital” business model. We implement the model in SS Medika hospital Jakarta, Indonesia for 3 years.
Findings:After 3 years of implementation, 517 elective surgical operations have been done successfully in 2017 by SS Medika with zero surgical sites infection and zero re-admission. It fixed costs is 25.8% from total hospital costs.
Interpretation: Nano-hospital business model improves surgery service accessibility and patient safety in SS Medika minimally invasive surgery hospital.
Introduction
New delivery models and health facility concepts are emerging in American healthcare in response to several broad trends: a focus on population health management, improving access to services, delivering care cost-effectively, and providing the best possible patient experience are driving the development of micro-hospitals. These modern, scalable facilities offer integrated healthcare and wellness services in rural, suburban and high-growth communities. The goal is not to build a full-service stand-alone acute care hospital on a smaller scale, but to develop a patient-centric facility closer to home that is tightly focused on market needs, while leveraging the scale, capabilities and resources of a broader health system.
Micro-hospitals typically operate seven days a week, 24 hours a day, and on average are 30,000 to 40,000 square feet in size with eight to ten inpatient beds for short-stays and observation. Most micro-hospitals are small-scale, fully licensed inpatient facilities. In general, no two micro-hospitals are exactly the same in design or services provided, but the majority of micro-hospitals tend to be located in areas and markets that are unable to support full-service hospitals. As such, micro-hospitals may be viewed as a low-cost entry into smaller markets, with the ability to expand services as needed. Micro-hospitals are designed to accommodate overnight stays but are primarily used to assess and treat lower-acuity inpatient medical conditions closer to a patient’s home and in a more cost efficient manner than a full-service hospital.(4)
Although surgery service delivery costs is a complex enterprise with many interconnected parts we can organized it into four categories of cost (based on similar root causes) that are prioritized by the magnitude of their impact and the difficulty in addressing them; Inherent costs; Structural costs; Systemic costs and Realized costs.(1)
Inherent costs: “What do we do?” In 2016 there are 2,601 hospitals all across Indonesia (2), 556 (21,4%) of those hospitals consider to be small hospital, traditional trend of hospital development in Indonesia is to be bigger and grow their “Product” lines with no specified target market and mission. As the hospital grow to be bigger the Structural costs: “How do we do it?” is inevitable, “square meter” needs for the building rise while the minimum for hospitals in Indonesia is only 1,250 m2 /13,500 square feet. Systemic costs: “How well do we do it?” is the next consequence, process to deliver service tend to be more complex, hospital organization tends to be bigger, drove us away to use automation. Realized costs: “How well do we apply ourselves?” Big hospitals need more resources to run their business, while resources are always limited.
Nano-hospital business model is a modification from the existing micro-hospital business model, the characteristic differences from the two models can be seen in Table 1.
Table 1. Different characteristic between Nano-Hospital and Micro-Hospital
Nano-hospital concepts start by “breaking the atoms”, we break all of the unit/elements contribute on medical service delivery, “Repair, Change, Adopt the atoms” and finally “Combine those atoms” to produce new “alien” hospital management system.
Methods
In 2014 we start to implement the business model; we choose small existing hospitals near to the supreme referral hospital in Indonesia (Cipto Mangunkusumo Hospital) to implement our business model. SS Medika Hospital located 600 meters (walking distant) from Cipto Mangunkusumo, the 1,300 m2 /14,000 square feet hospital now focuses on providing ear, nose, throat and orthopaedic surgery only. It provides only a minimum number of beds (25) and has a staff of 50 people of whom 10 are specialist doctor and 2 are sub-specialist doctor. It outsources services such as diagnostic tests, nutrition service, laundry and other “non-revenue producing” posts.
Customized Integrated Hospital System is implemented that allows medical record to be store electronically, The Lean “Pull” implementation with only single queue needed at the start of the process for the whole “Takt” surgical service delivery process (in-patient/out-patient), Electronically controlled warehouse reduce requirements to purchase, receive, maintain and deliver drugs. Human Resources process is control digitally from recruitment to pension, doctor and clinical privileged integrated with the e-medical record, real-time medication error and infection control monitoring is implemented. Real time hospital performance dashboard allow hospital leader to make fast-accurate top-level decision making.
Figure 1. SS Hospitals Integrated Nano-Hospital System Model Future Development
Findings
After 3 years of implementation SS Medika Hospital main variable cost item is doctor medical fees which comprise 43.4% of total hospital costs. Total Operational fixed cost is 25.8% of total hospital costs that include staffs salary and building maintenance and annual net profit increase 180.6%.
In 2017, 517 elective surgical operations have been done successfully in 2017 by SS Medika with zero surgical sites infection and zero re-admission.
After the first success implementation SS Hospitals looking to open second flagship hospital with nano-hospital concepts in Fatmawati-Jakarta which is located 400 m (walking distance) from Fatmawati Hospital, Jakarta-Indonesia to answer the Indonesian universal health coverage challenges in 2019.
Conclusion
Nano-hospital business model improves surgical accessibility and safety in SS Medika Hospital. Technologies advancement is a vital element to implement this business model. We build the technology in the center/first and surround it with the other management elements.
Further research and computer system development needed to revise and review this preliminary business model to be implemented globally in low-income and middle-income countries with under-develop universal health coverage system.
Sources
1. Health system fitness & A proven approach to transformational cost reduction, PWC https://www.strategyand.pwc.com/media/file/Health-system-fitness.pdf
2. http://www.depkes.go.id/resources/download/pusdatin/lain-lain/Data_dan_Informasi_Kesehatan_Profil_Kesehatan_Indonesia_2016_smaller_size_web
3.https://dinkes.kedirikab.go.id/konten/uu/97467PMK_No._24_ttg_Persyaratan_Teknis_Bangunan_dan_Prasarana_Rumah_Sakit.pdf
4. http://www.lancasterpollard.com/NewsDetail/tci-ho-micro-hospitals
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