Inpatient Facilities and Services

1. Inpatient Facilities and Services Chapter 8

2. Learning Objectives • 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

3. 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

4. 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

5. Introduction Construction and operatns of a hospital are governed by: • federal laws, • state health departments regulations, • city ordinances, • JCAHO, • fire codes, and • sanitation

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. Utilization Measures and Operational Concepts • Discharges • Inpatient Days • Average Length of Stay • Capacity • Average Daily Census • Occupancy Rate

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. Hospital Employment • Staffing ratios per occupied bed has increased • Look at Tabl 8-3, page 297 • Quality has not improved greatly with more staff

22. Hospital Types • Most are voluntary, nonprofit, short-stay, 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

23. Hospital Classification by Ownership • Public • Voluntary • Proprietary

24. 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

25. Hospital Classification by Ownership • Public • Have higher utilization • ALOS highest in federal hospitals • due to growing number of elderly veterans

26. 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

27. 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

28. 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

29. 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

30. Hospital Classifications Length of Stay • Short stay • ALOS < 30 Days • patients suffer acute conditions • may include long-term care • Long-term Hospitals • 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

31. Hospital Classifications Type of Service 1) general hospital 2) specialty hospital 3) psychiatric hospital 4) rehabilitation hospital 5) children’s hospital

32. Hospital Classifications Type of Service • 1) General hospitals • variety and broad set of services for various conditions • general and specialized medical • obstetrics • diagnostics • treatment • surgery • Most hospitals in U.S. are general

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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

39. 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

40. 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

41. 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

42. Other Hospital Types 1) Teaching 2) Church-affiliated 3) Osteopathic

43. 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

44. 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

45. 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

46. 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

47. 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

48. Management Concepts Hospital governance • Board of Trustees • governing body, board of directors • CEO • Administrator / President • Medical Staff • Chief of Staff • heads the medical staff

49. 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 with: • building codes • fire safety • climate control • space allocations • sanitation

50. 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