Transcript Inpatient Facilities & Services

Inpatient
Facilities and
Services
Chapter 8
Learning Objectives
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Recognize the evolution of hospitals
Survey the growth of hospitals
Understand reasons for hospital declines
Measure hospital operations and utilization
Differentiate between types of hospitals
Differentiate between for profit and nonprofits
Comprehend hospital governance
Identify ethical issues and the future of
hospitals
Introduction
• Inpatient
– requires an overnight stay in a health care facility
• Hospital
– an institution with at least 6 beds whose
function is to deliver patient services,
diagnostics and treatment
• must be licensed
• have an organized physician staff
• provide continuous nursing service under an
Registered Nurse
Introduction
Othr Hospital Characteristics:
– a governing body is responsible for
hospital conduct
– a CEO with responsible for operations
– medical records on each patient
– prescription services in the hospital,
supervised by a registered pharmacist
– food service to meet patient needs
Introduction
Construction and operatns of a hospital
are governed by:
– federal laws,
– state health departments regulations,
– city ordinances,
– JCAHO,
– fire codes, and
– sanitation
Introduction
• “Medical Center”
– used by hospitals to reflect
specialization and a large scope of
services
• Hospital / health system:
– multihospital chains
– provides a variety of health care
services
• Look at Fig 8-1, page 283
Transformation of the U.S.
Hospital
Institutions of:
– social welfare
• food and shelter
– care for the sick
• voluntary hospital financed through donations
– medical practice
• surgeries, x-ray, prescription, labs were available
– medical training and research
– htlh service consolidation
• reductions in inpatient stays, inpatient less
profitable
Expansion of U.S. Hospitals
• Hospitals grew due to surgical
procedures
• 6 factors in the growth of hospitals:
1) advances in medical service
2) development of specialized technology
3) advances in medical education
4) development of professional nursing
5) growth of health insurance
6) role of government
Expansion of U.S. Hospitals
• Development of Professional Nursing
– Florence Nightingale transformed nursing
– trained nurses, hygiene
• Growth of Health Insurance
– Great Depression closed many hospitals
– insurance allowed people to pay for health
care
– increased the demand for health care
Expansion of U.S. Hospitals
Role of Government
– 1946 The Hospital Survey and Construction Act
• “Hill Burton Act”
• Federal grants given to states for new community
hospital beds, but would be under federal control
• Greatest factor to increased nation’s bed supply
• By 1980, reached the goal of 4.5 beds per 1,000 population
– Look at Fig 8-2, page 289
• Grew non-profit community hospitals to help give
uncompensated care and outgrew for-profits
• Medicare and Medicaid also had an impact on number of
beds
Hospital Downsizing Since 1985
Due to:
– Changes in Reimbursement
• Cost-plus to DRGs
– Rural Hospital Closures
• Due to economic constraints
• Swing beds
– for rural hospitals to create revenue to switch the
use of beds between acute, long-term care, skilled
nursing
Hospital Downsizing Since 1985
Due to:
– Impact of Managed Care
• transformed delivery with cost containment
• emphasized alternative delivery settings
• lowered hospital profitability
• hospitals consolidated to cope
Utilization Measures and
Operational Concepts
• Discharges
• Inpatient Days
• Average Length of Stay
• Capacity
• Average Daily Census
• Occupancy Rate
Utilization Measures and
Operational Concepts
Discharges
– total number of patients discharged
from a hospital acute care bed in a
given time period
– total number of patient discharge per
1,000 population
• an indicator of access and utilization
• newborns not included in admissions, so
discharge not included for accuracy
• Look at Tabl 8-2, page 292
Utilization Measures and
Operational Concepts
• Inpatient Days
– a night spent in the hospital by a
person admitted as an Inpatient
• Days of care
– cumulative at of patient days over a
time period
Utilization Measures and
Operational Concepts
Average Length of Stay (ALOS)
= total days of care / total number of discharge
= 559.1 / 120.3
– measures how many days a patient on average
spends in the hospital
– an indicator of:
• severity of illness
• average inpatient resources used for each category
of patient
– Look at Tabl 8-2, page 292
– Look at Fig 8-6, page 294
Utilization Measures and
Operational Concepts
Capacity
– Size is determined by number of beds
set up and staffed
– 84% of community hospital in U.S. have
fewer than 300 beds
– Average size of a community hospital is
168 beds
– Rural hospital has 65 beds
– Urban hospitals have 231 beds
• Look at Fig 8-8, page 295
Utilization Measures and
Operational Concepts
Average Daily Census
=tot inpatient days during a period of time
(days of care) / number of days
– 101 = 3131 / 31
– average number of beds occupied per day in a
hospital
– estimates the number of inpatient receive care
each day at a hospital
– defines occupancy of inpatient beds in a
hospital
Utilization Measures and
Operational Concepts
Occupancy Rate
= average daily census / average number
of beds (capacity)
– a percent of beds occupied
– indicates the proportion of a hospital’s
total inpatient capacity that is truly
utilized
– used in nursing homes
– a measure of performance
• Look at Fig 8-9, page 29
Hospital Employment
• 1983 - 1986, declined by 2.3%
• 1989, 6.9% increased or 4.3 million due to
outpatient reimbursement
• 1996 - 2001, employment increased 3%
– more rapid growth next 10 years
• 12 million jobs in U.S. health care
– 45% in hospitals, 4% of civilian population
employed
– Average hourly earning highest in hospitals
• $17.45 for non management workers
Hospital Employment
• Staffing ratios per occupied bed has
increased
• Look at Tabl 8-3, page 297
• Quality has not improved greatly with
more staff
Hospital Types
• Most are voluntary, nonprofit, shortstay, general hospitals
– State and local government owned are
next
• For profit (investor-owned)
– Federal hospitals
» Look at Fig 8-10, page 298
• Endless variation, no simple
categories
Hospital Classification by Ownership
• Public
• Voluntary
• Proprietary
Hospital Classification by Ownership
Public
– First appeared when almshouses and
pesthouses evolved into hospitals
– owned by federal, state or local governments
– connotes government ownership
– not always open to the general public
– Veterans Administration, the largest federal
hospital system
– psychiatric hospitals deinstitutionalizing
– provide 1/3 of all uncompensated care
Hospital Classification by Ownership
• Public
– Have higher utilization
– ALOS highest in federal hospitals
• due to growing number of elderly veterans
Hospital Classification by Ownership
Voluntary Hospitals
– nongovernment, privately owned
hospitals operated on a nonprofit basis
– owned and operated by community
associations or other nongovernment
organizations
– the financial backing is done voluntarily
by citizens without government
Hospital Classification by Ownership
Voluntary Hospitals
– Mission:
• to benefit community where they’re located
• operating expenses covered by patient fees,
third party reimbursement, donations,
endowments
• largest group of hospitals
– Look at Fig 8-10, p-g 299
• 2000, 52% of all hospitals, 60% of all beds
Hospital Classification by Ownership
Proprietary Hospitals
– for profit
– investor-owned
• owned by individual, partners, corporations
– (ie HCA, Tenet)
– operated for financial benefit to
stockholders
– have lowest occupancy rate
Hospital Classifications
Multiunit Affiliations
– two or more hospitals
• Look at Tbl 8-4, page 300
– most systems operated by nonprofit corps
– Adv:
• economies of scale
• wide spectrum of care
• access to capital
– VA largest hospital system in U.S., 172 medical
centers
Hospital Classifications
Length of Stay
– Short stay
• ALOS < 30 Days
• patients suffer acute conditions
• may include long-term care
– Long-term Hospitals
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ALOS > 30 days
many state-run mental hospitals
demand has declined, even nursing homes
2000,
– 131 long-term care hospitals, 496 psychiatric
hospitals, 4 tuberculosis hospitals
Hospital Classifications
Type of Service
1) general hospital
2) specialty hospital
3) psychiatric hospital
4) rehabilitation hospital
5) children’s hospital
Hospital Classifications
Type of Service
– 1) General hospitals
• variety and broad set of services for various
conditions
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general and specialized medical
obstetrics
diagnostics
treatment
surgery
• Most hospitals in U.S. are general
Hospital Classifications
Type of Service
– General is not less specialized or inferior
to specialty hospital
– difference is the nature of services, not quality
– specialty has narrow range of services for specific
conditions or patients
Hospital Classifications
Type of Service
2) Specialty Hospitals
• serves distinct service niche
• admits certain types of patients with certain
illnesses
• can incl psychiatric, rehab, tuberculosis,
children hospitals
• emerging specialty hospitals:
– orthopedic and cardiology
Hospital Classifications
Type of Service
– 2) Specialty Hospitals
• physicians believe they’re more efficient
• physicians not on call as much
• physicians have opportunity to invest
• raises legal questions
• skimming the cream
Hospital Classifications
Type of Service
3) Psychiatric Hospitals
• provides diagnostics and treatment for patients
with psychiatric-related illness
• provides psychiatric, psychological and social
work services
• state government usually have responsible for
mentally ill
Hospital Classifications
Type of Service
– 4) Rehab Hospitals
• therapeutic service to restore maximum
function in patients
• includes amputees, spinal cord or head injuries
– accident or sport injuries
– stroke victims
• treatment usually after orthopedic surgery
• provides PT, OT, Speech, language pathology
Hospital Classifications
Type of Service
5) Children’s Hospital
• community-based
• facility designed for chronic, congenital
cardiac and orthopedic ped problems
• usually provide strong rehab programs
Hospital Classifications
Public Access
– Community hospital
• nonfederal short-stay hospital
• facilities and services available to general
public
• Mission:
– serve the general community
• can be proprietary, voluntary or owned by
government
• can be a general or specialty hospital
• 2000, 84.6% were community hospitals
Hospital Classifications
Location
– Urban hospitals
• located in a metropolitan statistical area
– population with 50,000+ people, usually inner city or
suburbs
• have higher costs, because of high salaries
• offer broader scope
• more complex care
– Rural hospitals
• not in a metropolitan area
– Inner city urban and rural both treat poor
and elderly
Hospital Classifications
Size
– no standard classification by size
– no economies of scale seen other than
around 100 beds
• Look at Fig 8-12, p 305
Other Hospital Types
1) Teaching
2) Church-affiliated
3) Osteopathic
Other Hospital Types
1) Teaching
– approved residency programs for
physicians
– hs 1+ graduate residency programs
approved by the AMA
– nursing and other professionals do nt
qualify
– provide medical training, research
opportunities, and specialized care
– usually possess latest medical technology,
diverse group of physicians
Other Hospital Types
1) Teaching
– 400 Council of Teaching Hospitals and
Health Sys (COTH)
• train 3/4 of all physician residents
– major and minor teaching hospitals
• depends on types of residencies
– offer tertiary care services
– usually
• located in economically stressed, older inner
cities
• owned by state or local government
• provide disproportionate and of
uncompensated care
Other Hospital Types
2) Church-affiliated Hospitals
– Catholic sisterhoods first established
– often community general hospitals
– owned or influenced by church groups
– do not discriminate in giving care
Other Hospital Types
3) Osteopathic Hospitals
– advocates treatment that is corrective of
the joints and tissues, emphasizing diet
and environment
– Community general hospitals
– approximately 200 osteopathic hospitals
– takes a holistic approach
– development because of the split with
physicians
Nonprofessional Hospitals
501(c)(3)
– grants tax-exempt status
– exempt from federal, state and local taxes
– must provide:
1) defined public good, service, education, welfare
2) no profit to any individual
– 80% of hospitals are nonprofit
– usually involved with comm outreach
– CEOs eval on performance and outreach
– community health is entrusted to the board
Management Concepts
Hospital governance
– Board of Trustees
• governing body, board of directors
– CEO
• Administrator / President
– Medical Staff
• Chief of Staff
– heads the medical staff
Licensure, Certification
and Accreditation
Licensure
– state government oversees with own set
of standards
– must be licensed to operate
– carried out by state departments of health
– emphasizes physical plant compliance
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building codes
fire safety
climate control
space allocations
sanitation
Licensure, Certification and
Accreditation
Certification
– allows hospital to participate in Medicare
and Medicaid
– Department of Health and Hospitals
development conditions of participation
• Department of Health and Hospitals contract
with state departments to inspect
Licensure, Certification and
Accreditation
Accreditation
– JCAHO evolved from ACS, AHA, AMA in
1951
• private, nonprofit
– JCAHO
• sets standards and accredits most:
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general, long-term care, psychiatric hospitals
substance abuse prgms
outpatient surgery centers
urgent care clinics
group practices
community health centers
hospices and HH agencies
labs
– voluntary
Legal Rights
• Patient Bill of Rights
– Patient Self-Determination Act of 1990
– applies to all health care facilities
accepting CMS
– given to all patients on admission
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confidentiality
consent
decisions re: medical care
information on diagnostics and treatment
right to refuse treatment
formulation of advance directives
Legal Rights
• Informed consent
– right to make an informed choice
regarding medical treatment
– physician must give all information a
patient asks or should be informed to
make a decision
– form signed and put in patient’s records
Legal Rights
Advance Directives
– patient’s wishes regarding continuation or
withdrawal of treatment when patient lacks
decision-making capacity
– 3 types:
1) Do Not Resuscitate (DNR)
– patient rathers death than have poor quality of life
– done in writing before incapacitated
2) Living will
– patient’s wishes when not able to make a decision
– a statement, usually written by a competent adult when
patient does not want life-sustaining measures
3) Durable power of attorney
– written, legal document,
– patient appoints someone else to act as their agent for
decision making when patient unable
Ethical Decision Making
• Ethic committees
– development guidelines and standards for
resolving medical ethics
– interdisciplinary
– moral agent
• led by administrator
• led by a higher calling
Legal Rights
• Patient Bill of Rights
• Informed Consent
• Advance Directives
• DNR
• Living will
• Durable power of attorney
– Medical durable power of attorney