The Hospital

Hospital is a place wherein sick people and injured people are being attended to and cared for.

Institution is a significant and persistent element (as a practice, a relationship, an organization) in the life of a culture that centers on a fundamental human need, activity or value, occupies an enduring and cardinal position within a society, and is usually maintained and stabilized through social and regulatory agencies.

History and Development of Hospital

Hospital had their origin in Indian and Egyptian culture during the sixth century. Evolution of the hospital is related to the sociological development of the individual's expansion of interest beyond himself and his family to the welfare of the community. Although early hospitals were really places to remove people from society to protect society, is, the insane, the incurables, and the contagious, other hospitals were developed through religious and divine motives. The temples of the gods in early Greek and Roman civilization were used as hospitals where healing was associated with divine powers, while continued illness or death was associated with lack of purity. Greek temples were forerunners of the modern hospital in the sense that they provided refuge and treatment for the sick and also provided for the teaching of young medical students. Such temples as the Temple of Aesculapius (Greek god of Medicine) existed in 1134 B.C., which the temple at Kos, Greece was where Hippocrates (born about 460 BC) practiced.

One of the dominant factor in the development and expansion of hospitals was the religious influence. Prior to the Christian Era, hospitals were temples dedicated to the god of medicine in which care of the sick was accompanied by magical, mystical, and religious ceremonies. The doctrines of Jesus Christ intensified the emotions and virtues of love, pity, and charity. These strong motivating forces toward one's fellow man fave impetus to the expansion of hospitals.

Another major factor in the development and expansion of hospitals devolves from a military influence. Much of the impetus toward medical and surgical progress over the centuries has come from the urgent need for care of the wounded on the battlefield. This was true during the Roman Empire; it was also true in the United States before, during, and after the Civil War. The Civil War, however, focused attention on the inadequacy of hospital construction and also on the lack of nursing care. Lincoln requested Catholic Sisters to care for wounded army personnel, because hospital care was so poor. The work done in the army set a pattern for improvement in patient care and combined the military and religious influence on hospital development.

Other factors which have influenced the development and expansion of hospitals were:

1. The Flexner report on medical education (1910), which caused revolutionary developments in medical education per se and in medical internship training which helped the development of minimum standards for patient care in hospital surroundings.
2. The activities of Florence Nightingale during and after the Crimean War, which served as the basis for revolutionizing the quality of nursing care in hospitals and for the development of schools of nursing; and
3. The public interest in hospitals through greater dependence and improved confidence in hospital care. With support provided the finances for further development, expansion, and improvement in hospital facilities. This public interest extended its influence into private hospitalization insurance and into government participation in health care through social security and other health-related agencies.

One of the most significant governmental programs which has affected the development and expansion of hospital facilities in the US was the adoption (in 1946) by the congress of the Hospital Survey and Construction Act. Commonly known as the Hill-Burton Program, this act was passed to provide federal funds for hospital construction on a matching basis with local communities. From 1946 to 1973 hundreds of new hospitals have been built which hundreds of other hospitals have undertaken major expansion programs of existing facilities through the availability of government finances through the Hill-Burton Act.

Since that time a number of legislative amendments have been adopted by the Congress which made funds available for construction and improvement of various health-care facilities, including, medical and nursing schools, out-patient facilities, extended-care facilities, and specialized diagnostic and therapeutic facilities in hospitals. In addition, the Social Security Amendments of 1965 (Medicare) will have long range impact on the development and expansion of hospitals, because funds are made available to pay for services of medically indigent patients lacking means to pay hospitals for services rendered.

The National Planning and Resources Development Act was implemented in 1975 creating the development of Health Systems Agencies (HSAs). These agencies have the responsibility of effective health planning and development of health services, manpower, and facilities in local areas. Each has is responsible for:

1. Improving the health of residents of its health service area;
2. Increasing the accessibility, acceptability, continuity, and quality of services provided;
3. Restraining increases the cost of these services;
4. Preventing unnecessary duplication of health resources.

In 1983, Congress enacted significant changes in the methods by which hospitals are reimbursed for medicare patients in an effort to hold down the escalating hospital costs. A Prospective Payment System was developed to reimburse hospitals at a specific rate based upon the diagnosis of the patient diagnosis related group (DRG). The system of payment may affect other private reimbursement system.

The first hospital on the American continent was built by the Spaniards (led by Cortez) in 1524 – The Hospital of the Immaculate Conception in Mexico City. In 1663 its name was changed to The Hospital of Jesus of Nazareth, and it still exists today. In the American Colonies a hospital was built in 1663 on Manhattan Island for sick soldiers. The first incorporated hospital in the United States was the Pennsylvania Hospital, established in 1751 through the efforts of Dr. Thomas Bond to provide physicians in Philadelphia with a population of 300,000 had no hospital. Since 1873 the population of the United States has more than doubled but the number of hospitals has increased 44 times – from only 149 to approximately 7000.

Beyond the three basic essentials of human existence the hospital has become a necessary instrument for providing a fourth basic element of survival – health. The hospital serves as a major instrument through which the health professions are able to provide health to the people of the community. It is because of the increasing complexity of health care – diagnostic, preventive, and therapeutic – that the necessary trained personnel, facilities and equipment are consolidated into what is known as the hospital in order to provide the quality of care the public expects, demands and deserves.

Definition of Hospital in terms of form:

Hospital is best exemplified by the “registration of hospitals program.” In order to be registered under this program an institution must meet certain requirements which constitute the definition of a hospital. The American Hospital Association (AHA) has specific definitions for “General” and “Special” hospitals in order for these institutions to qualify for the association's registration program.

Requirements for Accepting General Hospitals for Registration:

1. The institution shall maintain at least six in-patient beds, which shall be continuously available for the care of the patients and who stay on the average in excess of 24 hours per admission.
2. The institution shall be constructed, equipped and maintained to ensure the health and safety of patients and to provide uncrowded, sanity facilities for the treatment of patients.
3. There shall be an identifiable governing authority legally and morally responsible for the conduct of the hospital.
4. There shall be a chief executive to whom the governing authority delegates the continuous responsibility for the operation of the hospital in accordance with established policy.
5. The shall be an organized medical staff of physicians that may include, but shall not be limited to dentists. The medical stall shall be accountable to the governing authority for maintaining proper standards of medical care, and it shall be governed by laws adopted by said staff and approved by the governing authority.
6. Each patient shall be admitted on the authority of a staff member shall be directly responsible for the patient's diagnosis and treatment. Any graduate of a foreign medical school who is permitted to assume responsibilities for patient care shall possess a valid license to practice medicine, or shall be certified by the Educational Council for Foreign Medical Graduates, or shall have qualified for and have successfully completed an academic year of supervised clinical training under the direction of a medical school approved by the liaison Committee on Medical Education.
7. Registered nurse supervision and other nursing services are continuous.
8. A current and complete medical record shall be maintained by the institution for each patient and shall be available for reference.
9. Pharmacy service shall be maintained in the institution and shall be supervised by a registered pharmacist.
10. The institution shall provide patients with food service that meets the nutritional and therapeutic requirements; special diets shall also be available.
11. The institution shall maintain diagnostic X-ray service, with facilities and staff for a variety of procedures.
12. The institution shall maintain clinical laboratory service with facilities and staff for a variety of procedures. Anatomical pathology services shall be regularly and conveniently available.
13. The institution shall maintain operating room service with facilities and staff.

Requirements for Accepting Special Hospitals for Registration:

1. The institution shall maintain at least six in-patient beds, which can be continuously availability for the care of the patients and who stay on the average in excess of 24 hours per admission.
2. The institution shall be constructed, equipped and maintained to ensure the health and safety of patients and to provide uncrowded, sanity facilities for the treatment of patients.
3. There shall be an identifiable governing authority legally and morally responsible for the conduct of the hospital.
4. There shall be a chief executive to whom the governing authority delegates the continuous responsibility for the operation of the hospital in accordance with established policy.
5. The shall be an organized medical staff of physicians that may include, but shall not be limited to dentists. The medical stall shall be accountable to the governing authority for maintaining proper standards of medical care, and it shall be governed by laws adopted by said staff and approved by the governing authority.
6. Each patient shall be admitted on the authority of a staff member shall be directly responsible for the patient's diagnosis and treatment. Any graduate of a foreign medical school who is permitted to assume responsibilities for patient care shall possess a valid license to practice medicine, or shall be certified by the Educational Council for Foreign Medical Graduates, or shall have qualified for and have successfully completed an academic year of supervised clinical training under the direction of a medical school approved by the liaison Committee on Medical Education.
7. Registered nurse supervision and other nursing services are continuous.
8. A current and complete medical record shall be maintained by the institution for each patient and shall be available for reference.
9. Pharmacy service shall be maintained in the institution and shall be supervised by a registered pharmacist.
10. The institution shall provide patients with food service that meets the nutritional and therapeutic requirements; special diets shall also be available.
11. Such diagnostic and treatment services as may be determined by the Board of Approval to be appropriate for the specified medical conditions for which medical services are provided shall be maintained in the institution, with suitable facilities and staff. If such conditions do not normally require diagnostic X-ray service, Laboratory service, or operating room service, and if any such services are therefore not maintained in the institution, there shall be written arrangements to make them available to patients requiring then.
12. When the institution provides pregnancy termination services, clinical laboratory services shall include the capability to provide tissue diagnosis.

Definition of Hospital in terms of broad purpose or mission:

The contemporary hospital is a community institution which is an instrument of society. It serves as the focal point for the coordination and delivery of patient care to its community. A hospital may be viewed as an organized structure which pools together all the health professions, the diagnostic and therapeutic facilities, equipment and supplies, and the physical facilities into a coordinated system for delivering health care to the public.

Classification of Hospital

Hospital may be classified in different ways by:

1. Type of Service:

• A. General Hospital – provides care to patients with any type of illness: medical, surgical, pediatric, psychiatric, etc.
• B. Special Hospital – are those which restrict the care they provide to special conditions, such as cancer, psychiatric, or pediatric cases.

2. Length of Stay:

• A. Short – Term Hospital – is one which the average length of stay the patient is less than 30 days. E.g. The patients with acute disease conditions and emergency cases, usually general hospitals are short-term, since acutely ill patients usually recover in less than 30 days.
• B. Long – Term Hospital – is one in which the average length of stay of the patient is 30 days or longer. E.g. Psychiatric or mental retardation conditions.

3. According to Ownership:

• A. Governmental Hospitals – Federal (Armed Forces Veterans Administration and Public Health Services), State, County, City / Municipality, City – County, Hospital District
• B. Non-governmental Hospitals – Non – profit ( Church related or operated) and other non – profit institutions. For profit ( individual, partnership and corporation)

4. Hospitals are generally classified by bed capacity in according to the following pattern:

• Under 50 beds
• 50 – 90 beds
• 100 – 199 beds
• 200 – 299 beds
• 300 – 399 beds
• 400 – 499 beds
• 500 beds and over

5. According to Level

• A. Primary Level Hospital
• B. Secondary Level Hospital
• C. Tertiary Level Hospital

Definition of Different Hospitals

1. Federal Hospitals – are owned and operated by various branches of federal government.
2. State Hospitals – are owned by the states and controlled by a board of control or division of the state government, or a similar organization responsible to state government.
3. County Hospitals – are owned by the county and are financed and controlled similarly to state hospitals, only on a county level. They are usually general hospital caring for the indigents.
4. City Hospitals – are owned, financed, and controlled by the city government. They are usually general hospital caring for the indigents.
5. The Proprietary or Private Hospital Organized for Profit – is usually a corporation composed of physicians, although, other businessman may be involved in the corporate profit-making structure.
6. Non – Profit, Non-governmental Grouping of Hospitals – some are church hospitals supported financially by fees from paying patients or by contributions from the several religious orders or churches.
7. Community Hospitals or Private Non – Profit Hospitals – are owned and operated by members of the community, but with no relationship to the local government.

Four Fundamental Functions of Hospitals

A. Patient Care – the modern hospital is charged with maintaining and restoring health to the community which serves. Two basic types of accommodation based on the patient's ability to pay:

• 1. The full pay or private patient 

• 2. The partially or totally medical indigent (charity) patient.

B. Teaching Education – important function of the modern hospital whether it is or it is not affiliated with a university. Two major forms:

• 1. Education of medical and allied health professional
• 2. Education of the patients

C. Research – hospitals carry out research as a vital function for two major purpose:

• 1. The advancement of medical knowledge against diseases
• 2. The improvement of hospital services

D. Public Health – prime objective is to assist the community in reducing the incidence of sickness and to increase the general health of the population.

Organization and Administration of Hospital

Governing Body – it is where the administrator, director, medical director or whatever the individual be titled must report.

Duties of the Governing Board performed through the CEO (Chief Executive Officer):

1. Responsible for the selection of competent personnel including the medical staff.
2. The control of hospital funds
3. The supervision of the physical plan

Internal organization of the Governing Board:

1. A president or chairman
2. Vice chairman
3. Secretary – CEO
4. Treasurer
5. Lawyer

Departments Classification

1. Services involve primarily the professional care of the patient:

• Example: Pharmacy, Blood Bank, Central Sterile Supply, Clinical Laboratory, Dental Service, Dietary and Nutritional Service, etc.

2. Services which involve primarily the business management or administration side of the hospital:

• Example: Accounting, Admitting, Business Office, Credit and Collection Computer Services, Engineering and Maintenance, etc.

The Medical Staff

The medical staff of a hospital falls in a different category organizationally than the departments. Physicians are independent agents taking care of their patients, and they utilize the hospital, its departments, facilities, and services to care for these patients. The governing board of the hospital and the community, which it represents exercise effective control over the medical staff, although the governing board neither originates nor implements medical policy, it is responsible for it, and while the board members are not competent to pass judgment on the professional care of the patients they are, as representatives of the ownership of the hospital, liable for dereliction pf duties established by law. Thus the board delegates a portion of its duties and responsibilities to its appointed medical staff to originate medical policy honestly and carry out his policy in good faith. To do this requires that the medical staff be organized to govern itself and appraise its own work, and yet be responsible to the governing board for the details of its work.

Duties of the Medical Staff

1. Providing professional care of the sick and injured in the hospital.
2. Maintaining its own efficiency.
3. Self – government
4. Participating in the educational program of the hospital.
5. Auditing its own professional work.
6. Advisory and assisting the administrator and governing board regarding medical policies.

Two Main Types of Hospital Staff

1. An Open Staff – one in which certain physicians other than those on the attending or active medical staff are allowed to utilize the private room facilities, provided they comply with the rules and regulations of the institution. These physicians are termed members of the “courtesy” medical staff; the hospital is termed an open staff hospital.
   
   
2. A Closed Staff – one in which all professional services, private and charity are provided and controlled by the attending or active medical staff; the hospital is termed as closed staff hospital. The closed staff, though it has minor drawbacks, is the more desirable for the average hospital and especially for the teaching hospital, because it allows careful selection of a group of specialists with excellent reputation.

Medical Staff Categories

1. An Honorary Staff – is composed of physicians who have been active in the hospital but who are retired, and of those to whom it is desired to do honor because of outstanding contribution.
2. The Consulting Medical Staff – consists of specialists who are recognized as such by right of passing specialty boards or belonging to the rational organization of their specialty, and who serve as consultants to other members of the medical staff.
3. The Active or Attending Medical Staff – is the group primarily concerned with regular patient care. It is the group most actively involved in the hospital. In internal staff government it is the authoritative body.
4. The Associate Medical Staff – is composed of junior or less experienced members of the staff.
5. The Courtesy Medical Staff – consists of those physicians who desire the privilege of attending private patients but who do not desire active staff membership.
6. The Resident Medical Staff – is composed of residents, who are full time employees of the hospital. These persons provide specific services, for which they receive education and experiences.