Fear, concern, fate, and hope: survival of hospital libraries

I came to the endeavor of librarianship after personal insight gained living in Europe. Anytime I was in a city for more than three days, I found the public library. There I could enjoy newspapers in a variety of languages. I came to believe there could be no better place than a library and no better calling for me than to be a librarian. Recently several themes for this editorial have percolated in my thoughts. As often seems to happen, different meetings, discussions, and readings have helped concentrate my ideas. I thank many of you who are not aware that your comments on lists or your ideas during presentations and meetings have helped crystallize a new belief. I fear that hospital libraries will have a hard time surviving unless librarians can show that we support the mission of the hospital. A mission of some hospitals is to educate and train new health care professionals, but ultimately all hospitals exist to provide the best possible patient care. My concern is how librarians can show that the library’s information services support clinical care. The fate of hospital libraries need not be closure. Hope is the antithesis of fate. My hope is that the hospital library will survive. Why do I believe this, and what can we do? This editorial will address a few of the factors that affect hospital libraries and that can help us demonstrate the library’s value.

I came to the endeavor of librarianship after personal insight gained living in Europe. Anytime I was in a city for more than three days, I found the public library. There I could enjoy newspapers in a variety of languages. I came to believe there could be no better place than a library and no better calling for me than to be a librarian.
Recently several themes for this editorial have percolated in my thoughts. As often seems to happen, different meetings, discussions, and readings have helped concentrate my ideas. I thank many of you who are not aware that your comments on lists or your ideas during presentations and meetings have helped crystallize a new belief. I fear that hospital libraries will have a hard time surviving unless librarians can show that we support the mission of the hospital. A mission of some hospitals is to educate and train new health care professionals, but ultimately all hospitals exist to provide the best possible patient care. My concern is how librarians can show that the library's information services support clinical care. The fate of hospital libraries need not be closure.
Hope is the antithesis of fate. My hope is that the hospital library will survive. Why do I believe this, and what can we do? This editorial will address a few of the factors that affect hospital libraries and that can help us demonstrate the library's value.

Technology drives change
In Blur: The Speed of Change in the Connected Economy, Stan Davis and Christopher Meyer challenge us to discover the ways that computer technology continues to revolutionize how things are done [1]. In a keynote speech at a Special Libraries Association (SLA) annual conference, Davis challenged librarians to look at SLA's ''Competencies for Special Librarians of the 21st Century'' and to make them customer centered. One of the salient points Davis made was that technology drives changes, and, while many of us may not like the changes, we cannot stop them.
We know the printed book will not die overnight, but in my opening paragraph are hints of change that computer technology brings. The newspapers I enjoyed reading in European libraries are now free on the Internet. With applications such as the University of Virginia electronic library, the Guttenberg Project, and Google's digitization projects with major universities, complete books are now online and millions more will be in ten years. Once online, they can be ''read'' to us.
We can talk more about other coming changes-the death of the keyboard, the cell phone-size computer, universal wireless access, online electronic journals-but we understand the impact. More and more information will not be in paper format. The coming changes imply that libraries as places need not exist. Decision makers are asking, ''Why have hospital libraries?'' Accountability comes for all, the ''evidence based'' movement Ⅲ Evidence-based medicine and evidence-based nursing: If we need to know how our hospital libraries can participate in the evidence-based health care movement, we have learning opportunities at annual meetings of the Medical Library Association (MLA), regional chapters, state library groups, or related professional groups. As increases in health care costs outpace annual cost-of-living inflation, health care leaders look to practicing health care based on the best evidence, in hopes that the best practices help give the best results at the best price. The thinking is that return on investment accountability has to be applied to health care. Hospital libraries support evidence-based health practices by providing access to the knowledgebase in the literature and through training clinicians to locate evidence in the literature. Ⅲ Evidence-based library and information practice (EBLIP): During the past seven years, the movement to bring evidence-based practice to librarianship has increased. Still, many hospital librarians may not know what this entails. Booth [2] provides a useful summary. Booth and Brice [3] also recently noted eight hoped-for achievements for EBLIP over the next three years: -form an international collaboration or association of evidencebased library and information practitioners -produce an internationally recognized consensus statement -increase practitioner involvement in determining research questions and priorities -continue dissemination of significant research findings through evidence summaries -increase use of ''implications for practice'' from published research findings -generate tools and techniques for increased use of the evidence and for promotion of reflective practice -integrate evidence-based practice and project management methodologies as tools for strategic planning -increase numbers of team-based examples of local EBLIP initiatives Librarians can incorporate EBLIP principles into their work to systematically demonstrate hospital libraries' value. Ⅲ Evidence-based leadership: My hospital is on a path to excellence in patient service. What makes this program different from previous continuous quality improvement work is its emphasis on leadership development and the hardwiring of service and operational excellence. The program is based on the knowledge that all of us in health care believe in our purpose, in our worthwhile work, and in making a difference. The health care flywheel of change and improvement turns ever faster when all of us align our principles, our passion, and our results [4].
At my hospital, we are implementing a process that continually asks patients how we are doing. A recent leadership development workshop brought to our attention the movement for evidence-based leadership. Keynote speaker Quint Studer discussed the Hospital Consumer Assessment for Healthcare Providers and Systems (HCAHPS) [5], the government's way of asking patients how they perceive the quality of care. The four rating scale terms in HCAHPS are ''never,'' ''sometimes,'' ''usually,'' and ''always''-absolute determinations that emphasize how important consistency of care is. Many of the survey questions ask about patients' receiving knowledge or information. Hospital librarians can find potential areas of service among the survey questions.
Studer made the point that hospital leaders will be expected to hardwire (as in ''always'') performance and achievement levels. As goals are set and aligned and as behavior is aligned to the goals, procedures must be aligned, too. I took the opportunity to talk with Studer about the EBLIP movement, noting that hospital librarians recognize the need to show how library practice supports the clinical care mission of our hospitals. His reply was noteworthy; to paraphrase him: ''Good. If they don't, they will end up on the cutting room floor.''

What I now believe we need to do
Hospital libraries support the diverse individuals and various needs of health care. Because so much is done for so many, we need to think of a mosaic to create the full picture of what hospital libraries do. We need to create and then to assemble many little pieces to create the ''big picture'' of hospital librarianship.
Accountability through basing decisions on sound evidence is key for clinical practice and, increasingly, library practice as well. I feel that it is critical that hospital libraries begin or continue system-atic evidence collection, such as customer service and operations data, to prove their case to their institutions. The following points illustrate steps hospital libraries can take now: Ⅲ Hospital librarians need to ask customers what is important to them and how the library rates in meeting the customer's expectations. Using the gap analysis survey model, we can survey our customers. I suggest we set measurable standards, for example, ''within 72 hours in our customer's hands,'' rather than statements open to interpretation, such as ''in a timely manner'' [6]. Ⅲ Hospital librarians need to know how long it takes to get an item to every customer and whether customers prefer a paper product or an electronic document delivered to a desktop computer. We have quarterly and annual DOCLINE data for summary reports on interlibrary loan and Loansome Doc activity. Other software, such as QuickDOC, gives us the flexibility to tabulate results for patrons, departments, or libraries for any period [7]. Without the library, the hospital does not have access to the international network of services the profession provides. Ⅲ The hospital library has to provide the best possible electronic access to information. Always. The hospital library needs to have fax equipment and the equipment to scan a copy from an original article and send that scan electronically. Ⅲ We need benchmarks to measure our comparative levels of achievement and to strive for the highest. Always. These benchmarks need to stress the availability and use of equipment and technology to serve our customers. For example, we need to ask, ''Does the library encourage use of Loansome Doc by its customers?'' Ⅲ We must communicate among ourselves and to our administrators the library's return on investment. We must ask our customers if what we provide them is used for clinical care, patient education, information, teaching, clinical education, or research. Hospitals will be evaluated by consumers, so we must show that we support the critical mission of the hospitals' employees and physicians [8,9]. Ⅲ We need to report to administrators what clientele we serve, how many, how often, and in what ways. We need to know how many ''unique'' individuals we serve. Do we serve 10% of the medical staff and 15% of the nurses? We need to set goals to improve that percentage every year. Libraries can report numbers of unique users of online resources, for example, and set marketing goals for the online resources. Ⅲ Hospital librarians often do not have the training, interest, or free time to do research, so I propose hospital librarians partner with academic institutions to do research.
We must start to create the pieces of the mosaic that demonstrate hospital libraries contribute to excellent clinical care. I encourage you to read Abels and Zach [8,9] and to think about an editorial by Plutchak [10]. When assembled from the small pieces that many hospital libraries can provide, our institutions' leaders and we can see a better picture of the composite library information services. With that comes the hope that the hospital library will continue to exist.