inpatient facilities and services chapter 8 learning objectives get a perspective on the evolution...

Inpatient Facilities

and Services

Chapter 8

Learning Objectives

• Get a perspective on the evolution of hospitals• Survey the growth of hospitals• Understand reasons for hospital decline• Measure hospital operations and utilization• Differentiate between types of hospitals• Differentiate between for-profit and nonprofit

hospitals• Comprehend hospital governance• Identify ethical issues

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 that include diagnostics and treatment

• must be licensed

• have an organized physician staff

• provide continuous nursing services supervised by RNs

IntroductionOther Hospital Characteristics:

– a governing body is legally responsible for hospital conduct

– a CEO is responsible for operations

– medical records on each patient

– pharmacy services supervised by a registered pharmacist

– food services to meet nutritional needs

IntroductionConstruction and operations of a hospital

are governed by:– federal laws – state health regulations – city ordinances– JCAHO standards – fire codes – sanitation standards

Introduction• “Medical Center”

– hospitals that offer specialization and a large scope of services

• Hospital / health system:– multihospital chain

– provides a variety of health care services

Transformation of the U.S. HospitalEvolution along five dominant functions:

1) social welfarealmshouses and pesthouses

2) care for the sickpublic and voluntary institutions

3) medical practice- medical science and technology

- hospital administration,

organization, efficiency

Evolution along five dominant functions, cont:

4) medical training and research

collaboration between hospitals and universities

5) consolidated systems

- organizational integration

- service diversification

Transformation of the U.S. Hospital

Expansion of U.S. Hospitals: Late 1800s to Mid-1980s

• Hospitals grew due to surgical procedures

• 6 factors in the growth of hospitals:1) advances in medical science2) development of specialized technology3) advances in medical education4) development of professional nursing5) growth of health insurance6) role of government

Expansion of U.S. Hospitals

• Development of Professional Nursing– Florence Nightingale transformed nursing– Efficiency of treatment; 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. HospitalsRole of Government

– Hospital Survey and Construction Act (Hill Burton Act), 1946

• Federal grants to build nonprofit community hospitals

• Uncompensated care was a condition• Biggest factor to increase nation’s bed supply

• By 1980, goal of 4.5 beds per 1,000 population reached

– Public health insurance (Medicare and Medicaid)

Hospital Downsizing: Mid-1980s Onward

– Changes in Reimbursement• Cost-plus to DRGs• Decrease in inpatient utilization

– Rural Hospital Closures• Economic constraints• Swing beds enabled some to survive

– Impact of Managed Care • Emphasis on cost containment• Efficient utilization of resources (care in

alternative settings)

Utilization Measures and Operational Concepts

• Discharges

• Inpatient Days

• Average Length of Stay

• Capacity

• Average Daily Census

• Occupancy Rate

Utilization Measures and Operational Concepts

Discharges

– number of overnight patients a hospital serves in a given time period

– include newborns and deaths

– discharges per 1,000 population

• an indicator of access and utilization

Utilization Measures and Operational Concepts

• Inpatient Day (patient day)

– a night spent by a patient

• Days of care

– cumulative patient days over a time period

Utilization Measures and Operational Concepts

Average Length of Stay (ALOS)

– Days of care / Discharges– An indicator of severity of illness and resource use

– Highest in federal hospitals

– Sharp declines precipitated by PPS and managed care

– Alternative settings and technology enabled quicker discharges without harm to patients

Utilization Measures and Operational Concepts

Capacity

– Size is determined by number of beds set up and staffed

– 84% of community hospitals in U.S. have fewer than 300 beds

– Average size of a community hospital is 165 beds

Utilization Measures and Operational Concepts

Average Daily Census

– average number of beds occupied per day

– days of care / number of days

Utilization Measures and Operational Concepts

Occupancy Rate

– percent of beds occupied

– [average daily census / number of available beds (capacity)] x 100

– a measure of performance

Hospital Employment

• 4.7 million full-time equivalent workers

• 4% of all service jobs

• US hospitals are better staffed than those in other nations

• But, quality outcomes may not be greater

Hospital Types

• Over half are private nonprofit (voluntary)

• State and local government owned are the next largest group

• For-profit or investor-owned

• Federal hospitals are the fewest in number

Hospital Types

• Numerous ways to classify

• Classifications are not mutually exclusive

Hospital Classification by Ownership

• Public

• Voluntary

• Proprietary

Hospital Classification by Ownership

Public (government ownership) – First appeared when almshouses and

pesthouses evolved into hospitals

– Owned by federal, state or local governments

– Federal hospitals are open to special groups only (native Americans, military, veterans)

– VA runs the largest hospital system (federal)

– States run mainly psychiatric hospitals

– Local hospitals (county or city-owned) serve a high proportion of disadvantaged groups

• Public

– Overall high utilization

– ALOS highest in federal hospitals• The veteran population is aging

Hospital Classification by Ownership

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

– their mission is to benefit the community

– largest group of hospitals

Hospital Classification by Ownership

Proprietary Hospitals (investor-owned)

– for profit

– operated for the financial benefit of owners or stockholders

– have gained market share in recent years

Hospital Classifications: Multiunit Affiliation

– Two or more hospitals (owned/ leased/ managed)

– Almost half of all US hospitals are chain affiliated

– Nonprofit chains dominate

– Advantages:• economies of scale• wide spectrum of care; variety of markets• access to capital• access to management resources and expertise

Hospital Classifications: Length of Stay

– Short stay hospitals• ALOS < 25 days; for acute conditions

– Long stay hospitals• ALOS > 25 days• Psychiatric; LTCHs; chronic care

– LTCHs

• Must meet Medicare guidelines

• Patients with complex medical needs

• Rapid growth has occurred

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• Broad set of services for various conditions

–general and specialized medical–obstetrics–diagnostics–treatment–surgery

• Most hospitals in U.S. are general

Hospital Classifications

Type of Service

2) Specialty Hospitals• Narrow range of services for specific conditions

or patient types

• Exceptions: psychiatric care or substance abuse

• Examples: rehabilitation, children’s, women’s, orthopedic, cardiac, oncology, etc.

• Many are physician-owned

Hospital ClassificationsType of Service

2) Physician owned specialty hospitals

• Physicians find efficiency and financial benefits in hospitals they own

• Control and time flexibility

• Legal issues: Stark Laws (self-referral)

• Cream-skimming and emergency care is another concern

Hospital Classifications

Type of Service

3) Psychiatric Hospitals

• provides psychiatric, psychological and social work services

• state mental hospitals continue to treat people with severe and persistent mental illness

Hospital ClassificationsType of Service

4) Rehabilitation Hospitals

• therapeutic services to restore maximum function in patients

• Medicare rule: 75% of the inpatients must require intensive rehabilitation

• PT, OT, Speech/language pathology

Hospital ClassificationsType of Service

5) Children’s Hospitals– Specialize in complex, severe, or chronic

illnesses among children

– Generally have neonatal and pediatricintensive care, trauma care, andtransplant services

– In most communities, general hospitals serve as de facto children’s hospitals

Hospital Classifications

Public Access

– Community hospitals

– Nonfederal, short-stay • Serve the general public• Can be proprietary, voluntary or government

owned (only state or local)• Can be a general or specialty hospital• 85% of US hospitals are community hospitals

Hospital ClassificationsLocation

– Urban hospitals • located in a metropolitan statistical area (MSA)• have higher costs: high salaries, competition,

broader and complex services – Rural hospitals

• not in a MSA

Inner city urban and rural hospitals treat poor and elderly disproportionately

Hospital Classifications

Location—Rural hospitals

Critical Access Hospitals

– Authorized under the Balanced Budget Act, 1997• To save many small rural hospitals• Maximum 25 beds• Emergency services must be available• Cost-plus reimbursement

Hospital ClassificationsSize

– no standard classification by size

– no economies of scale seen beyond 100

beds

– medium and large hospitals• extensive and specialized services

• technology

• highly-trained personnel

Other Hospital Types

1) Teaching

2) Church-affiliated

3) Osteopathic

Other Hospital Types

1) Teaching hospitals

– AMA approved residency programs for physicians

– Academic medical centers:

Teaching hospitals organized around medical schools; heavily engage in research and clinical investigations

– Approx. 400 are members of the Council of Teaching Hospitals and Health Systems (COTH)

Other Hospital Types1) Teaching hospitals: Main characteristics

– Offer most specialties and subspecialties

– Broad and complex scope of services (often have tertiary care services)

– Research activities– Additional reimbursement (than DRGs) to offset

salary and training costs– Technology intensive

– Many located in economically depressed areas

Other Hospital Types

2) Church-affiliated Hospitals

– first established by Catholic sisterhoods

– mostly community general hospitals

– owned or influenced by church groups

– do not discriminate in giving care

– spiritual and dietary emphases are often present

Other Hospital Types

3) Osteopathic Hospitals

– holistic approach along with the use of diagnostics, pharmaceuticals, surgery, etc.

– advocate treatment that is corrective of the joints and tissues, and emphasize diet and environment

– community general hospitals

– approximately 200 osteopathic hospitals in US

– developed because of earlier split with allopathic physicians

Nonprofit Hospitals

IRS Code, Section 501(c)(3)

– tax-exempt status

– must provide some defined public good (service, education, welfare—charity care)

– no distribution of profits to any individual

– executive pay may not be deemed unreasonably high

Nonprofit HospitalsKey Issues

– They often compete head on with for-profit hospitals (institutional theory)

– For-profit hospitals often provide charity care at levels similar to nonprofits

– Quality of care is often similar between for-profit and nonprofit hospitals

– Hence, tax exemption is controversial

Nonprofit Hospitals

Some suggestions:

– Engage in community outreach (health assessments, education, wellness, support groups, etc.)

– Promote better health and well-being for the community

– Fill unmet health needs

Management Concepts

Hospital governance– Board of Trustees

• governing body, board of directors– CEO

• Administrator / President– Medical Staff

• Chief of Staff–heads the medical staff

Hospital Governance

Board of Trustees– Legally responsible for operations

– Establish mission and long-term direction

– Establish policy guidelines

– Approve plans and budgets

– Monitor performance

– Appoint and evaluate the CEO

– Approve appointment of medical staff

– Committees:

• Executive Committee

• Medical Staff Committee

Hospital Governance

CEO– Responsible for day-to-day operations

– Leadership

– Accomplish mission and objectives

Hospital GovernanceMedical Staff

– Chief of staff (medical director)

– Chiefs of service (for specialties) in major

hospitals

– Committees:• Executive

• Credentials

• Medical records

• Utilization review

• Infection control

• Quality improvement

Licensure, Certification and Accreditation

Licensure– A hospital must be licensed to operate

– State government oversees w/ own set of standards

– Emphasizes physical plant compliance with:• building codes• fire safety• climate control• space allocations• sanitation

Licensure, Certification and Accreditation

Certification– Not mandatory (required only if a hospital

wants to participate in Medicare and Medicaid—most do)

– A federal function

– Hospitals must comply with the conditions of participation—federal standards forhealth, safety, and quality

Licensure, Certification and Accreditation

Accreditation

– JCAHO or American Osteopathic Association

– Accreditation is a private function

– It is voluntary for the hospital

– It confers deemed status

Ethics Principles

• Respect for others– Autonomy: empowerment

– Truth telling: honesty

– Confidentiality: privacy

– Fidelity: duty and promises

• Beneficence—benefit to the patient

• Non-maleficence—do no harm;

benefits > potential harm

• Justice—fairness and equality

Legal Rights

• Patient Bill of Rights– Patient Self-Determination Act of 1990– Inform patients of their rights upon admission

– Main rights:• confidentiality• consent re: medical care• information on diagnosis and treatment• right to refuse treatment• formulation of advance directives

Legal Rights• Informed consent

– right to make an informed choice regarding medical treatment

– right to obtain complete current information on diagnosis, treatment, and prognosis

– Patient-centered care: organizational culture that promotes patient involvement, respects preferences, and need for information

Legal Rights

Advance Directives– Patient’s wishes regarding continuation or

withdrawal of treatment when patient lacks decision-making capacity

– Three types:1) Do Not Resuscitate (DNR)—no CPR

2) Living will– Patient’s wishes are indicated in advance

– Main drawback: Limited in scope

3) Durable power of attorney– Patient appoints someone else to make decisions

– Main drawback: patient’s wishes may be bypassed

Ethical Decision Making• Ethics committees

– develop guidelines and standards

– address ethics issues

– multidisciplinary

• Moral agent• Health care managers• Moral responsibility to put patient needs above

those of the organization• Ethics transcends compliance with the law

Public Trust

• Hospitals to be regarded as community assets• Maintain financial and operational integrity• Genuine concern for the welfare of patients and the

community• Concerns about quality and safety must be

addressed• Fraud and abuse generates negative publicity and

erodes public trust