AUG/SEPT 2004
Volume 28
No. 8
 



N E W Sx I T E M S

Medicare warns
of provider scam

Unacceptable abbreviations chart

Revised & renewed protocols need IRB review, dean says

US News and World Reports Hospital Rankings

Common charges available for patient perusal on request

Role of clinician educators reviewed

Report needle sticks

From Tumor Board to Public Affairs, liver suregon believes in outreach

Infusion treatment area

Hematopathology Moment

 

 

 

 

 

 

 

 

 

 

 

 

 

 


Working towards greater efficiency

by: LAWRENCE M. SHUER


Eighteen months ago (Feb. 2003) I talked with you in this column about how as practicing physicians we could ease a hospital bed shortage by facilitating timely discharges for our patients. Our goal was to make discharge decisions earlier in the day or even the night before so patients could be discharged by an 11 a.m. target.

Many of you, with the active support of the hospital, rallied to this appeal to use beds efficiently. Nevertheless, we have become a victim of our own success and the hospital bed crunch is getting worse.

The reasons for the bed shortage are several. Many of our clinical programs have experienced unprecedented growth in the wake of several successful faculty recruitments. We are also busier because our referral streams from existing medical staff members are maturing; many of you are referring more patients!

SHC is taking steps to accommodate expanding services. To help serve some of the surgical volume, the hospital is evaluating a proposal to make the third floor of the new Advanced Treatment Center (a.k.a. The Cancer Center) into a new ambulatory surgery center [ASC]. Such a move would vacate the existing ASC, and that space could be retrofitted to expand cath lab facilities - thus bringing more patients. The hospital has also decided to install a second Cyber knife unit to increase our capabilities to treat patients with cancer of the brain and other parts of the body.

This increase in services and volume is occurring without a corresponding growth in bed capacity. Periodically we have no beds to place patients coming from the emergency department or from outlying hospitals via the transfer center, because more patients in our operating rooms and cath labs are filling those beds.

We really need more medical surgical beds, but it is not likely that we will be building a new patient tower in the near future. (However, something clearly will have to be done before 2030 when the seismic codes for hospitals will require us to phase out patient care in the B, C, G and H units.)

So we are faced with a simple reality: we are increasing the number of patients who need to stay overnight in a fixed or nearly static number of beds. Clearly we are going to have to use beds we already have more efficiently.

Managing an individual patient is based on quality medicine, as well as such issues as the patient's mobility, family support and available community services. But managing a hospital's overall bed utilization is based at least in part on probability - actually in much the same way that airlines and hotels take and usually honor reservations even when they are busy. As in other industries, the more you can plan, the more you can predict institutionally - even if "individual results may vary."

Yes, some of the discharge dates will change, and this variability is built into the system, just as Marriott or Hilton know that some guests will miss their incoming planes and won't need the room they have booked. But without giving planning and yield management our best shot, we are doomed to unacceptable inefficiencies rather than manageable variabilities.

The theory behind the 11 a.m. discharge time is that it will free up beds for new patients earlier in the day - particularly for patients coming out of the operating rooms, emergency department, etc. who otherwise would be "parked" somewhere before a bed is free. A medical surgical bed free by late morning also means that space is available for those patients ready to transfer out of the intensive care units. When a patient is moved from an ICU earlier in the day, an ICU bed is thus freed for surgical patients and patients waiting to come to SHC through the transfer center. And thus the cycle continues - efficiently and with our patients' comfort in mind.

We must never forget that patients are the major beneficiary of a predictable discharge time. Once a discharge date is targeted, the case managers can work with physicians, nurses, families and other staff members to make sure that durable medical supplies are appropriately ordered and/or that plans have been made for a bed at a skilled nursing facility or rehabilitation unit, etc.

Put simply, we need the various teams to do what they can to alter their patterns of patient care by planning ahead. As physicians the key is to write discharge orders as early in the day as feasible - or even better, with careful planning, the night before. Improvements will require some planning on our part. For example, when patients are kept in the house waiting for a procedure or a diagnostic test, the hospital is being used inefficiently. We need to develop a system to notify schedulers early that a particular test or procedure is needed before a patient can be discharged - and a bed can be freed.

In the long run collaboration and planning will help us serve more patients and continue to grow our clinical programs. If you have any ideas about how we can improve our patient flow within the hospital - or for that matter the clinics - please do not hesitate to contact either me or Elizabeth Polek, LCSW, director of Social Work and Case Management. You can send your suggestions to me at:

(lshuer@stanford.edu)