Inpatient Facilities and Services

Inpatient Facilities and

Services

Chapter 8

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

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 service2) development of specialized technology3) advances in medical education4) development of professional nursing5) growth of health insurance6) role of government


• 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


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


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


• 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


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


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



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


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


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, 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

Hospital Classification by Ownership

• Public

• Voluntary

• Proprietary


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


• Public

– Have higher utilization

– ALOS highest in federal hospitals• due to growing number of elderly veterans


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


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


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


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


Type of Service

1) general hospital

2) specialty hospital

3) psychiatric hospital

4) rehabilitation hospital

5) children’s hospital


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


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


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


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


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


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


Type of Service

5) Children’s Hospital

• community-based

• facility designed for chronic, congenital cardiac and orthopedic ped

problems

• usually provide strong rehab programs


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


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


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


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 Types1) 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


2) Church-affiliated Hospitals

– Catholic sisterhoods first established

– often community general hospitals

– owned or influenced by church groups

– do not discriminate in giving care


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 Hospitals501(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 with:• building codes• fire safety• climate control• space allocations• sanitation


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


Accreditation

– JCAHO evolved from ACS, AHA, AMA in 1951• private, nonprofit

– JCAHO• sets standards and accredits most:

– 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

– covers:• 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 RightsAdvance 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

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Inpatient Facilities and Services

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