Nearly every hospital leader in America will tell you their hospital is all about patient-centered care. Of course, we know this isn’t true in many cases, especially when it comes to hospital capacity management. Though many institutions will deny to its last dying breath that they have any priorities that supercede patient care, nearly all do.
They usually go like this: first priority is high margin surgical cases; second priority is high margin cardiac cases; third priority is lower margin surgical cases (or if it’s a tertiary care facility than transfers and directs). It sounds cold, but it is what it is.
Coming in last on the priority list is usually the Emergency Department.
Patients in the ED are ignored while patient beds are filled with higher priority patients. This accumulation continues to ratchet down the available beds the ED has to treat patients, usually during its highest volume periods, such as weekdays from noon to midnight. Mondays and Tuesdays in the ED are terrible, because those are the days that surgeons and specialists like to schedule their procedures (this would be physician-centered care), meaning there are fewer hospital beds available to admit patients from the ER. This results in higher left-without-being-seen rates and unhappy patients in in the ED. Wednesdays and Thursdays the load lightens a little, until Friday finally arrives, with low volumes in surgery and cardiology, allowing the ED to start to decompress. Then the weekend arrives, hospital provider staffing shrinks and the volume of discharges from the hospital is cut in half. Then Monday comes and the cycle repeats.
This is hospital capacity management 101, which really isn’t capacity management at all.
Enlightened hospital leaders – and there are plenty of them out there, if you look – have embraced a different idea about capacity management. These leaders think of the ED as being the front door of the hospital. Accordingly, they move resources, implement new processes, such as well-run and resourced observation units, to address the capacity issues directly impacting patients waiting for a hospital bed. These leaders recognize that the Emergency Department interacts with more patients, family, friends and providers than any other area of the hospital, and as such can be the source of enormous creativity around capacity management, not just impacting the ED, but the entire hospital.
Good emergency management groups embrace creative problem solving to manage volume, using processes like provider in triage, bedside registration, diversion hours, geographic pod staffing, and a series of time-sensitive metrics that would put other areas of the hospital to shame. The ED manages natural variability on a daily basis, never knowing what the next minute or hour will bring. Staffing hours have to be demand mediated and have a high degree of flexibility.
Clearly if any one area of a hospital has a keen understanding of capacity management, it’s the Emergency Department. There, key metrics define care delivery, process improvement, efficiency, quality and cost.
True hospital capacity management anticipates the needs of the organization and adjusts and coordinates artificial variability so it provides optimal bed use for all the patients.
Much has been written about “leveling” – leveling out operating room schedules, leveling out the cath lab schedules, getting a consistent number of cases requiring specific bed types to levelled all week long. But levelling still isn’t about the patient. There are some instances in which it is—an acute myocardial infarction presenting to the ED or a triple AAA requiring the operating room. But if the Emergency Department has 25 patients waiting for a bed at 3pm in the afternoon on a Tuesday, do you think anyone will suggest closing the operating room, or refusing directs or transfers? Not on your life. That’s because capacity management 101 by and large isn’t about the patients. It’s about surgeons and cardiologists – their lifestyle, or their needs, and where they sit on the totem pole of the organization.
This will only change when the organization determines that the most important thing in their hospital is the patient. In my decades of working in healthcare, I have seen physician-centered care, nurse-centered care, resident-centered care, or even administrative-centered care. Rarely have I seen patient-centered care.
So if you’re wondering whether a hospital and its leadership are enlightened, take a close look at its plans for capacity management.
- Robbin Dick, MD (Read other posts by Robbin Dick)