How Does a Hospital Work?

One of the interesting and very sad realities is that despite being a physician, I know very little about how a hospital works. We got one lecture on this at the end of medical school, and that's probably more than most. Learning about the hospital is very much part of the "hidden curriculum" and acculturation of working at one. Many things confuse me; for example, how come nurses are hired by the hospital or medical center whereas doctors (medical staff) are not? Why is the CEO usually not an MD? How do costs and revenues work? Is the hospital paid by procedure or by diagnosis? What about a clinic? Do labs and radiology count as inpatient or outpatient services (surprisingly, I have a hunch that for billing, they're more similar to outpatient services). Who's the chief operational officer or the chief medical officer or the chief of staff, and what do they do? So much happens in the background, behind the eyes of patient and provider. I couldn't tell you the order of magnitude of hospital expenses or where they go (non-MD personnel? equipment? capital improvements? overhead?). I couldn't tell you how many operators we have or how many people working on insurance claims.

Then there are the nuts and bolts of regulation: what does it mean to be credentialed? What could cause my hospital (or residency program) to lose accreditation? What happens if we think a fellow physician shouldn't be practicing? Now that we're becoming more and more aware of patient safety, I'm learning about infection control and quality improvement. But I'm still not sure what they check: perioperative beta blockers? ICU glycemic control? acute MI responses? codes? other things?

Most medical students know about the Joint Commission because when they inspect the hospital, we need to be on our best behavior. But what about CMS (Centers for Medicare and Medicaid services) or the Leapfrog group or this business with "centers of excellence"? We all have fuzzy notions of what is tracked (time to antibiotic for pneumonia, readmission rates for CHF, surgical site infections, resident work hours) but we never formally get taught these things. As we switch from rotation to rotation, we learn to use two patient identifiers for a time-out, expect read-back with verbal orders, and look for checklists. But what are the repercussions of failing to adhere to standards? If my publicly reported hospital performance is marred, how does that affect my day-to-day life? Or the hospital's viability? What about the new-fangled physician ratings websites that allow you to look up specific providers? How does that work?

I think this is interesting. The culture of safety will be a great boon to patients and to the delivery of care. But because it's so new, there's little formal instruction. Likewise, we don't need to know hospital finances but what if one day we want to become an administrator ourselves? This sort of thing isn't in the curriculum and is lower priority than the knowledge base to take care of patients, but we don't want to omit it completely.