Affluent, fast-growing suburbs of major cities are fertile ground for hospital growth. Hospitals in older, established areas face obstacles such as more patients with no insurance and lower paying government insurance. Urban hospitals are often overcrowded with emergency rooms backing up because patients have nowhere to go when no rooms are available. Studies at Yale University found emergency room overcrowding and boarding has reached crisis levels, saying:
In one of the new studies, researchers found that boarding times — or the amount of time patients were kept in the emergency department after clinicians had determined they should be admitted — were related to hospital occupancy rates, or the percentage of staffed inpatient beds that are occupied.
For the study, Yale researchers… found that when occupancy exceeded 85%, boarding times exceeded this four-hour standard.
When ERs get overcrowded tempers rise, stress levels rise, medical errors increase, causing quality of care to suffer. What is the cause of ER overcrowding? Doctors. Of course, physicians must admit all patients. Every medical service received must be ordered by a doctor, so it makes sense to blame them. However, that is not the point. Specifically, it is not doctors per se, it is surgeons.
Back in the 1990s Ukrainian émigré, Eugene Litvak, began studying operations management in hospitals to figure out how to make them more efficient. Dr. Litvak, a mathematics PhD, found that random ER visits were not responsible for ER overcrowding, surgeries were. The following was reported by Kaiser Family Foundation (KFF) Health News:
Some days, surgical patients crowded the hospital, so doctors and nurses sweated through expensive overtime. Others, the place was quiet and the hospital lost money staffing empty beds. Nobody could figure out why.
One day, in Mike Long’s office, they noticed a couple of these sheets sitting one on top of the other.
One had a line showing scheduled surgeries — more this day, fewer that day. The other had a line showing, day by day, how many hospital beds were full.
What Eugene Litvak and his colleague, Mike Long discovered was that surgeons like to schedule surgeries early in the morning, early in the week.
The hospital got jammed — and the ER got backed up with patients waiting for a bed upstairs — when there were more surgeries scheduled.
And there was a definite pattern: There were a LOT more scheduled surgeries early in the week, on Mondays and Tuesdays.
While the solution may sound obvious, it was far from easy.
People in the hospital did not want to believe what Eugene’s data showed.
And they did NOT want to hear some engineer telling them when they should operate.
Doctors like to schedule surgeries early on Monday and Tuesday for several reasons. They want their work week over sooner. They want to operate when they feel refreshed from relaxing over the weekend. They know weekends at the hospital have less staffing and they want to reduce the risk of being called in to check on their surgery patients over the weekend.
Here is the thing: resistance from surgeons (and the status quo) prevented hospitals from adopting Litvak’s recommendations.
Surgeons are trained to fight for those Monday morning block times– and in hospitals, they have a lot of clout. They bring in patients, and administrators are afraid to cross them.
Over the years numerous hospitals have hired Litvak but found it hard to accept or adopt his recommendations. One hospital that did, Cincinnati Children’s Hospital, estimates its annual savings at $137 million a year. No other hospital went as far to adopt Litvak’s program as Cincinnati Children’s Hospital, however.
The operating room is like an assembly line. Patients come in, are operated on and sent to recover in a hospital bed in a room. The surgery is a huge revenue source. To a lesser degree, recuperating in a hospital room is as well. Unlike most assembly lines, only a select few workers are allowed to perform the tasks. While it would make sense to schedule surgery around the clock, seven days a week that is not practical due to a lack of available surgeons and anesthesiologists. Eugene Litvak may blame it on institutional inertia, and surgeons who like their Monday-Tuesday routine. I would add it is arguably because hospitals do not compete on price or efficiency, or really any form of competition in the traditional sense.
When I was doing operational improvement consulting we understood this problem well, and we tried to develop a system that would encourage surgeons to spread out their surgeries during the week. This is not hard to envision, but we could never come up with an incentive that didn’t violate federal anti-kickback laws. Just one more way government regulation raises health care costs.
I suspect hospital administrators have complained for decades that a flood of surgery patients the first of the week causes wide variations in occupancy throughout the week. Too bad there isn’t a way to have congestion pricing for surgery.
Agree. We could do congestion pricing for patients / insurers, but there was no legal way to adjust the incentives for the surgeons, and that’s all that matters.