Rapid responses are electronic comments to the editor. They enable our users
to debate issues raised in articles published on bmj.com. A rapid response
is first posted online. If you need the URL (web address) of an individual
response, simply click on the response headline and copy the URL from the
browser window. A proportion of responses will, after editing, be published
online and in the print journal as letters, which are indexed in PubMed.
Rapid responses are not indexed in PubMed and they are not journal articles.
The BMJ reserves the right to remove responses which are being
wilfully misrepresented as published articles or when it is brought to our
attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not
including references and author details. We will no longer post responses
that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
I agree with Dr. Wilson that we will see many more specialised, niche
-type health care facilities in the future,(1) rather than general, all-
purpose giant mammoths that dominate the hospital landscape currently.
However, I would argue that this paradigm change will be brought about for
economic and operations management reasons as much as through state-of-the
-art technological advances.
It has been well documented that there is a "steep learning curve"
for most medical interventions, especially complicated ones. (3-6) Centres
which have a higher case volume generally report better clinical outcomes
at a lesser cost. (2-7) This effect appears to hold true for most
procedures irrespective of the technological sophistication involved.
(2,4,6) The experience of Shouldice Hospital in Ontario, Canada is a
typical illustration. The Hospital only performs abdominal hernia repairs,
a relatively low-tech procedure. Yet, it is so successful with low relapse
rates, so successful in creating a social experience for its patients, and
so relatively inexpensive, that former patients celebrate the
anniversaries of their operations annually with a gala hotel banquet. (8)
What is so special about the Hospital? It is a focused factory.
The term "focused factory" was first coined by Harvard Business
School professor Wickham Skinner in 1974 to argue that complex and overly
ambitious factories were at the heart of America's productivity crisis in
the late '60s and early '70s. He concluded that "simplicity and
repetition breed competence". (9) Many American companies heeded his call,
among them McDonald's and Kodak, which grew and prospered since. In health
care, the parallel is striking. Health care costs are soaring in Europe,
America and parts of Asia; while common health indicators have remained
much the same in the past decade or so. In short, there is an efficiency
and productivity crisis in health care provision. Previous attempts to
rectify this problem have met with little success: managed care has so far
failed to satisfy Americans and NHS reforms have yet to deliver its
promise to Britons. Perhaps we should apply the concept of focused
factories to restructure our health care systems. It is high time for
hospitals to learn how to focus on a limited, concise, manageable set of
interventions, procedures and services. Hospital chief executives must
learn to structure policies and supporting services so that they focus on
one or a few explicit objectives instead of many conflicting and
inconsistent goals from different clinical departments. (10) Only then can
they realise the enormous clinical and financial economies of scale which
has made Shouldice Hospital the envy of general surgical units everywhere.
Procedure- or organ system- based focused factories are already
proliferating in the form of "centres of excellence" in some parts of the
world. I believe we should continue to move towards the focused factory
model in hospital services provision in the 21st century. Therein lies a
solution to our present health care organisational conundrum.
References
1. Wilson CB. Hospitals of the future: the impact of medical technologies
on the future of hospitals. BMJ. 1999;319:1287.
2. Gordon TA, Burleyson GP, Tielsch JM, Cameron JL. The effects of
regionalization on cost and outcome for one general high-risk surgical
procedure. Ann Surg. 1995;222:211-2.
3. Bennett CL, Adams J, Bennett RL, et al. The learning curve for AIDS-
related Pneumocystis carinii pneumonia: experience from 3,981 cases in
Veterans Affairs Hospitals 1987-1991. J Acquir Immune Defic Syndr Hum
Retrovirol. 1995;8:373-8.
4. Bennet CL, Stryker SJ, Ferreira MR, Adams J, Beart RW Jr. The learning
curve for laproscopic colorectal surgery. Preliminary results from a
prospective analysis of 1194 laparoscopic-assisted colectomies. Arch
Surg. 1997;132:41-4.
5. Shook TL, Sun GW, Burstein S, Eisenhauer AC, Matthews RV. Comparison of
percutaneous transluminal angioplasty outcome and hospital costs for low-
volume and high-volume operators. Am J Cardiol. 1996;77:331-6.
6. Ritchie JL, Maynard C, Chapko MK, Every NR, Martin DC. Association
between percutaneous transluminal coronary angioplasty volumes and
outcomes in the Healthcare Cost and Utilization Project 1993-1994. Am J
Cardiol. 1999;83:493-7.
7. Grumbach K, Anderson GM, Luft HS, Roos LL, Brook R. Regionalization of
cardiac surgery in the United States and Canada. Geographic access,
choice, and outcomes. JAMA. 1995;274:1282-8.
8. Heskett JL. Shouldice Hospital Limited. Case No. 9-683-068.
Boston:Harvard Business School Publishing Division, 1983.
9. Skinner W. The focused facory. Harvard Business Review. May-June,
1974:113-22.
10. Herzlinger R. Market-driven health care: who wins, who loses in the
transformation of America's largest service industry. Reading, MA:Addison
-Wesley. 1997.
Competing interests:
No competing interests
17 November 1999
Gabriel M Leung
Assistant Professor
Department of Community Medicine, University of Hong Kong, Hong Kong
Charles Wilson's article offers both an exciting and fascinating
insight into the future of hopsitals and the impact of medical
technologies. With many areas discussed offering significant improvement
to healthcare outcomes of the patient. My concern lingers around he issue
of 'patient process'through the healthcare journey in a hospital or
community setting.
For adding technology to a bad patient process will do nothing but
automate a bad patient process and offer little to improve patient care.
My hope is that the hospital of the future invests more into become
centered around the patient and that patient process improvement is the
imperative of any planning or development undertaken to modernise a
hospital.
The role of technology to assist this improvement is unquestionably
helpful; but without the vital improvement in the flow of the patient
process, the hospital of the future will be very similar to the hospital
of the past, only automated.
Competing interests:
No competing interests
16 November 1999
David Probert
NHS Management Trainee (North Thames Region)
On an Elective with the Institute for Healthcare Improvement in Boston, USA
Focused factories - specialty hospitals of the future
I agree with Dr. Wilson that we will see many more specialised, niche
-type health care facilities in the future,(1) rather than general, all-
purpose giant mammoths that dominate the hospital landscape currently.
However, I would argue that this paradigm change will be brought about for
economic and operations management reasons as much as through state-of-the
-art technological advances.
It has been well documented that there is a "steep learning curve"
for most medical interventions, especially complicated ones. (3-6) Centres
which have a higher case volume generally report better clinical outcomes
at a lesser cost. (2-7) This effect appears to hold true for most
procedures irrespective of the technological sophistication involved.
(2,4,6) The experience of Shouldice Hospital in Ontario, Canada is a
typical illustration. The Hospital only performs abdominal hernia repairs,
a relatively low-tech procedure. Yet, it is so successful with low relapse
rates, so successful in creating a social experience for its patients, and
so relatively inexpensive, that former patients celebrate the
anniversaries of their operations annually with a gala hotel banquet. (8)
What is so special about the Hospital? It is a focused factory.
The term "focused factory" was first coined by Harvard Business
School professor Wickham Skinner in 1974 to argue that complex and overly
ambitious factories were at the heart of America's productivity crisis in
the late '60s and early '70s. He concluded that "simplicity and
repetition breed competence". (9) Many American companies heeded his call,
among them McDonald's and Kodak, which grew and prospered since. In health
care, the parallel is striking. Health care costs are soaring in Europe,
America and parts of Asia; while common health indicators have remained
much the same in the past decade or so. In short, there is an efficiency
and productivity crisis in health care provision. Previous attempts to
rectify this problem have met with little success: managed care has so far
failed to satisfy Americans and NHS reforms have yet to deliver its
promise to Britons. Perhaps we should apply the concept of focused
factories to restructure our health care systems. It is high time for
hospitals to learn how to focus on a limited, concise, manageable set of
interventions, procedures and services. Hospital chief executives must
learn to structure policies and supporting services so that they focus on
one or a few explicit objectives instead of many conflicting and
inconsistent goals from different clinical departments. (10) Only then can
they realise the enormous clinical and financial economies of scale which
has made Shouldice Hospital the envy of general surgical units everywhere.
Procedure- or organ system- based focused factories are already
proliferating in the form of "centres of excellence" in some parts of the
world. I believe we should continue to move towards the focused factory
model in hospital services provision in the 21st century. Therein lies a
solution to our present health care organisational conundrum.
References
1. Wilson CB. Hospitals of the future: the impact of medical technologies
on the future of hospitals. BMJ. 1999;319:1287.
2. Gordon TA, Burleyson GP, Tielsch JM, Cameron JL. The effects of
regionalization on cost and outcome for one general high-risk surgical
procedure. Ann Surg. 1995;222:211-2.
3. Bennett CL, Adams J, Bennett RL, et al. The learning curve for AIDS-
related Pneumocystis carinii pneumonia: experience from 3,981 cases in
Veterans Affairs Hospitals 1987-1991. J Acquir Immune Defic Syndr Hum
Retrovirol. 1995;8:373-8.
4. Bennet CL, Stryker SJ, Ferreira MR, Adams J, Beart RW Jr. The learning
curve for laproscopic colorectal surgery. Preliminary results from a
prospective analysis of 1194 laparoscopic-assisted colectomies. Arch
Surg. 1997;132:41-4.
5. Shook TL, Sun GW, Burstein S, Eisenhauer AC, Matthews RV. Comparison of
percutaneous transluminal angioplasty outcome and hospital costs for low-
volume and high-volume operators. Am J Cardiol. 1996;77:331-6.
6. Ritchie JL, Maynard C, Chapko MK, Every NR, Martin DC. Association
between percutaneous transluminal coronary angioplasty volumes and
outcomes in the Healthcare Cost and Utilization Project 1993-1994. Am J
Cardiol. 1999;83:493-7.
7. Grumbach K, Anderson GM, Luft HS, Roos LL, Brook R. Regionalization of
cardiac surgery in the United States and Canada. Geographic access,
choice, and outcomes. JAMA. 1995;274:1282-8.
8. Heskett JL. Shouldice Hospital Limited. Case No. 9-683-068.
Boston:Harvard Business School Publishing Division, 1983.
9. Skinner W. The focused facory. Harvard Business Review. May-June,
1974:113-22.
10. Herzlinger R. Market-driven health care: who wins, who loses in the
transformation of America's largest service industry. Reading, MA:Addison
-Wesley. 1997.
Competing interests: No competing interests