HSA 3111: Inpatient Facilities and Services 1 Dr. Lawrence West, Health Management and Informatics...

HSA 3111: Inpatient Facilities and Services

1Dr. Lawrence West, Health Management and Informatics Department, University of Central Floridahttp://systems.cohpa.ucf.edu/lwest

Topics

• Terminology• History of Hospitals• Hospital Expansion Phases• Hospital Downsizing Phase• Hospital Organization• Nonprofit Hospitals• Hospital Management• Ethical and Legal Issues

“It may seem a strange principle to enunciate as the very first requirement in a hospital that it should do the sick no harm”

Florence Nightingale



Terminology

• “Inpatient” involves an overnight stay at a healthcare facility– “Outpatient” does not– Usage is not dependent on the

• Severity of the condition• Complexity of the treatment



Terminology (cont.)

• “Hospital”– At least six beds (why not five?)– Organized physician staff– Licensed– Continuous nursing services– On site pharmacy services– Governing body and chief executive– Food service– Medical records services

Which of these characteristics

does a nursing home lack?



History of Hospitals

• Book identifies five distinct phases

1. Primitive institutions of social welfare

2. Distinct institutions for care of the sick

3. Organized institutions of medical practice

4. Advanced institutions of medical training and research

5. Consolidated systems of health services delivery• We are interested in the drivers of transformation

between stages– Help identify future trends



History of Hospitals (cont.)

• Primitive Institutions of Social Welfare– Through the late 1800s– “Poorhouses” for the destitute– Little medical treatment– “Pesthouses” isolated the sick with contagious

diseases– Very few of these institutions– Restricted to a few urban areas




• Distinct Institutions to Care for the Sick– Became widespread in the late 1800s

• A few notable exceptions prior to this time– Differentiated from the Poorhouses and

Pesthouses• Medical care was provided• A treatable illness was expected

• Why did we see such low prominence for hospitals in the HC system?– Or, where was healthcare coming from?




• Organized Institutions for Medical Practice– Late 1800s/Early 1900s saw huge transformations

in the practice of medicine• What were they?

– Hint: Contrast with medical effectiveness in the past

• How did they affect hospitals?– Hospitals became centers of medical practice

• Why? (This is hugely important)




• Organized Institutions for Medical Practice (cont.)– Hospitals required professional management and

organization• Departmental organization became common

(why?)• Management had to focus on efficiency

– Hospitals shifted focus to the acute stage of an illness

• Early cost containment strategy




• Medical Teaching and Research– Shift in medical care to hospitals resulted in

• Shift in medical education to hospital-centered knowledge

• Tight coupling between (some) hospitals and medical schools

– Partnerships– Unified ownership– Hospital practice for internships and

residencies




• Consolidated HC Delivery Systems– Late 20th Century changes have lead to new

models for hospitals• Economic pressures• Technological advances

– Cost pressures and technologies have reduced hospital stays

• Excess bed capacity → consolidation – Competition from new providers

• Outpatient surgery centers• Imaging centers

More Coming Up



Hospital Expansion Phase

• Hospitals expanded exponentially from late 1800s through mid 1980s

• Six drivers of expansion– Advances in medical science– Development of specialized technology– Advances in medical education– Development of professional nursing– Increased health insurance– Government involvement

• Construction• Medicare and Medicaid



Hospital Expansion Phase (cont.)



Hospital Downsizing Phase



Hospital Downsizing Phase (cont.)




• Pressures on Hospitals– Increased cost controls → Decreased

reimbursement• Shorter stays• Fewer admissions

– Increased competition• Improved technologies made more procedures

outpatient




• Downsizing affected hospitals in two ways– Hospital closings

• Marginal hospitals failed• Smaller hospitals hard hit• Rural hospitals hard hit

– Hospital mergers and acquisitions• Smaller and non-profit hospitals absorbed by

larger chains• Chains seeking to increase capacity in advance

of the baby book entering old age




• What are the implications of these figures?



Hospital Organization

• Hospitals come in a wide variety of– Ownership

models– Services

offered– Multi-hospital

structure



Hospital Organization (cont.)

• Public Hospitals– Government owned and operated

• Federal ownership exclusively for special populations

• State, county, & municipal focused on service to public

– High proportion of lower income and uninsured

– Financial and economic pressures squeezing these institutions

• Community Hospital—open to all comers




• Hospital Chains– See staffing differences between independent and

chain hospitals (Table 8-3)– Hospital chains realize economies of scope and

scale• Administrative overhead

– Billing and reimbursement– Facilities management– Governance– Information technology investments

• Lengthen the value chain




• Types of Hospitals– General hospitals

• Most common• Provide wide range of services

– Specialty hospitals• Rehabilitation• Focused disease (cardiac, cancer)• Psychiatric• Children’s or Women’s and Children’s




• Rural vs. Urban Hospitals– Urban (county population > 100,000)

• Higher costs• Broader scope of services

– Rural• Disproportionate number of poor• Cannot employ many specialist staff and

facilities full time• Funding increases available if designated a

Critical Access Hospital




• Operational costs by size




• Teaching Hospitals– Offer residency programs

• Receive targeted Medicare funding– Associated with a medical school (“Academic

Medical Center”)• Training• Research• Tertiary care in one or more specialties



Nonprofit Hospitals

• 80% of all private hospitals and 84% of all private hospital beds are nonprofit– Legal definition of nonprofit must be clearly

understood– Research discloses little difference in the behavior

between for-profit and nonprofit hospitals of similar size and location

– Nonprofit hospitals receive significant tax benefits– Under review to justify these exemptions



Hospital Management

• Hospitals are complex organizations– (But not the most complex)– Multiple stakeholders (List these groups!!)– Parallel governance structures distinctive

• Administrative management• Medical staff• Objectives often at odds with each other• Some staff accountable to both authority chains

– Pharmacy ‒ Nursing– Lab ‒ etc.



Hospital Management (cont.)

• Hospitals require licensure, accreditation, and various other certifications– Affect ability to operate– Affect ability to provide reimbursable services– Hospital management must continuously monitor

criteria for certifications, etc.



Ethical and Legal Issues

• Healthcare is fraught with opportunities for unethical behavior regardless of motivation– Fraud and many other acts are clearly wrong– But HC providers have ethical duties to respect

patient wishes even…• …if patient does not understand the science• …patient over- or undervalues a treatment• …patient does not understand the risk

– Patients (or surrogate) must give consent for treatment



Ethical and Legal Issues (cont.)

• Many practical ethical issues in HC revolve around “informed consent”– Patient understands the treatment and risks– Patient elects the treatment

• Patients are not always able to make informed consent– Minor children– Medically incompetent

• Advanced Directives can direct care in the event patient cannot

HSA 3111: Inpatient Facilities and Services 1 Dr. Lawrence West, Health Management and Informatics...

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