As a Stanford medical student, I have had a chance to rotate through four hospitals, each of which represents a different care setting. We see patients at Stanford Hospital (an academic medical center), the Palo Alto VA (a Veterans Affairs hospital), Valley Medical Center (a county hospital) and Kaiser Santa Clara (a community hospital in a large system).
For me, one of the biggest perks of rotating through multiple sites has been the opportunity to observe how workflow and provision of care differs between hospitals. Whether it’s admitting patients, scheduling follow-up, or even cleaning rooms, each hospital takes a slightly different approach.
This observation led me to think further about how and why hospitals set priorities. The ongoing discussion around health reform frequently refers to good health systems versus bad ones and describes aspects of care that all systems should provide. While I sympathize with the goal of standardizing best practices, rotating through different hospitals highlights how good care depends on context.
For example, I admitted a man presenting with a simple heart failure exacerbation at three different hospitals: Kaiser, Valley and the VA. At Kaiser, we rapidly stabilized and discharged him. Given the integrated nature of the system, we were able to schedule outpatient follow up for the very next day to discuss further management with his primary care doctor. The patient lived close by and we knew he would show up to his appointment.
At Valley, a patient came in with a nearly identical presentation so we acutely treated him the same way. However, he had an unstable living situation and hadn’t attended a follow-up appointment in several years (not atypical at Valley given that it serves as a safety-net hospital). My team decided to incorporate primary care into his hospitalization, including extensive counseling on his diet and several screening tests. These interventions extended his hospital course by another two days from the point he was medically stable to be discharged, but hopefully contributed to keeping him healthy long-term.
Finally, I saw a VA patient who had the same initial hospital course. However, the Palo Alto VA utilizes something of a hub and spoke model of care. In this case, it meant that although the patient lived in and received most of his care in the Central Valley (nearly three hours away), he traveled to Palo Alto for certain hospital-based and specialty services. Since he was already at the hospital, we added appointments with his urologist and endocrinologist so he wouldn’t have to make another trip. He ended up remaining at the hospital for an additional three to four days, but received treatment that would otherwise have been spread over time.
In each of these cases, the hospital admitted a patient with the same presenting problem but the course differed based on the unique social needs of the patient. This raises an interesting question: if four hospitals that have so much in common—large, tertiary care centers in Santa Clara County that are affiliated with Stanford—are so different, how should policymakers think about legislation that affects hospitals around the country?
There is a tension between standardizing care and giving providers flexibility to adapt to their local environment. Based on my experience, we are good at identifying medical best practices that should be standardized (e.g. when a patient has x condition, they should receive y intervention). But when it comes to broader concepts in health care delivery (for example, payment systems, risk adjustment, outcomes measures, etc.), we do not yet have models that are proven to work for different patient populations.
It is therefore worth exploring how competing models work in different settings. Despite the significant role of government and large institutions, health care is fundamentally a local enterprise. Proposals for reform should ensure it remains that way.