Fixed assets: Often overlooked area ripe for significant cost savings
Fixed assets: Often overlooked area ripe for significant cost savings
Hospitals play catch-up on recent gains in length-of-stay reduction
The practice of cutting length of stay (LOS) to reduce surgical costs has just about run out of gas. With LOS now cut to the bone at many facilities, the challenges QI professionals now are facing include how to maximize the use of fixed assets, reduce fixed overhead costs, increase the income-producing potential of certain hospital services, and prevent the problems that too often delay patients’ recovery. In this, the second part of our series on the future of QI, we’ll present expert advice on how to meet those challenges and take advantage of untapped opportunities for reducing costs.
QI professionals are just beginning to realize the impact of shortening LOS. Suzanne Richins, RN, MBA, FACHE, director of patient care at McKay-Dee Hospital in Ogden, UT, notes, "We haven’t planned for what’s going to happen to our patients when they need support during those first few days after surgery."
In Utah, where tightly-knit families and communities prevail, it’s not an issue. "But in other regions, it’s a problem," Richins observes. "Before home care benefits were cut, hospitals could discharge people who did not have family support and count on home care to see them through those first, critical 24 hours. But when home care benefits are scarce, it impacts the outcomes for those patients."
Richins’ concerns are well founded. Studies headed by Dorothy Jones, EdD, RN, FAAN, professor at Boston College School of Nursing, show that nine out of 10 ambulatory surgery patients called a physician within the first 24 to 72 hours of discharge. Mostly, they ask for stronger pain medications. Jones, who also is a nurse scientist at Massachusetts General Hospital in Boston, reports that "insufficient pain management led to other problems. People were unable to get out of bed and do their prescribed exercises."
Jones emphasizes the need for a much stronger pre-surgical patient education component. "The perception is that ambulatory surgery is easier and faster. But the reality is that patients have to be better prepared than they are now."
The degree of fatigue exceeded most people’s expectations, Jones explains. "If people went back to work in three or four days, as they were told they could, they often couldn’t make it through a whole day. Or if they made it through one whole day, many of them had to stay home the next day." The findings reveal that anticipated three-day recoveries actually took four to five days for 20% of the patients.
The lack of assistance at home during the first few days compromised the ease of recovery. "Even if patients prepared as they were instructed — with fluids in the refrigerator and home-delivered meals — they didn’t anticipate what would be involved in getting from the bed to the refrigerator or answering the door to take the delivered meals," Jones notes. Despite the findings, Jones doesn’t consider a reversal in ambulatory surgery trends a solution.
Nor does Anthony Dawson, RN, MSN, clinical director for perioperative services at New York Presbyterian Hospital in the New York Weill Cornell Center in New York City.
Generally, the less time people spend in the hospital, the better, he says. "It’s a sick environment because the people who are in the hospital these days are very sick. They’re not here for convalescence anymore. The less time surgical patients spend here, the less their risk of picking up nosocomial infections."
Yet a great many of New York Presbyterian’s patients risk the post-surgical difficulties that Jones describes. They don’t have support networks, either by choice or by circumstance.
Dawson explains that some don’t want their friends or families to know about the procedure, and they specifically choose to weather it alone.
Education prior to the procedure is critical to good outcomes for all patients and especially for those who don’t have a readily available caregiver. The elderly and those with comorbidities are particularly vulnerable to complications. Ideally, Dawson says, education should start through the physician’s office. Patients need to know the expected length of their procedure, type of anesthesia, and the requirement of an escort to take them home.
A pre-surgical telephone screening should cover anesthesia tolerance based on any past experiences and known allergies or adverse reactions to pain medications. "We tell patients that any sedation will make them too groggy to drive or cycle safely," Dawson says. Besides, there’s always the possibility that they’ll have unexpected nausea or that a procedure will require heavier sedation than anticipated. Even so, some patients foil a provider’s most conscientious efforts.
Dawson tells of one man who rode his bicycle to an endoscopy appointment — and he fully intended to ride it home. "We’d have tremendous legal liabilities if we released an unescorted person after sedation," Dawson explains. With a case like the cyclist, who had no relative or friend available, the hospital arranged a cab ride.
The Perioperative Service at New York Presby-terian calls each patient within 24 hours of discharge. "We don’t have many patients who need to come back to the emergency room for complications," he notes. (Learn more about patient experiences following outpatient surgery. See "Outpatient surgery fails on speedy recovery promise," p. 4.)
Untapped potential for better utilization
David Butz, co-director of the Center for Health Care Economics at the University of Michigan’s Business School in Ann Arbor, suggests several ways to improve the delivery of surgical services. But first, he insists, hospital administrators must upgrade the quality of the data they supply to physicians. "Hospitals are always telling physicians to reduce their costs, but it’s the rule rather than the exception to give them very little baseline data about their costs." Besides solid cost figures, Butz says, "any area of the hospital [including surgical services] would benefit from a rudimentary business plan."
Operating room schedules have a largely untapped potential for improvement. For example, he suggests starting the day with procedures of predictable lengths and moving the less predictable ones toward the end of the day. That would reduce the frequency of all-day backups.
Extended hours of surgery could reduce the overhead cost per patient. However, providers might want to explore a few feasibility issues first, such as:
• The risk of error among clinicians working outside their peak periods of mental alertness.
• Acceptance by patients and their family caregivers of starting surgery at 10:00 p.m., for instance, and leaving the surgical center during the wee hours of the morning.
In Part 1 of this series, Butz suggested that hospitals reduce the high overhead expenses of fixed assets such as aero-medical equipment (patient transport helicopters) by putting them to wider use. (See the discussion of outcomes from higher through-put in surgical services in the cover story, QI/TQM, December 2000.)
Vassar Brothers Hospital in Poughkeepsie, NY, applies a similar principle in several departments and achieves stunning results. The objective is simple, says John Mallegol, director of materials management at the 320-bed community hospital: "We wanted to stop the outflow of dollars and create revenue through reverse outsourcing.’" It started eight years ago, when Vassar Brothers acquired an ambulance service.
Today it contracts with all surrounding municipalities, transporting patients to Vassar Brothers and several other hospitals in the Poughkeepsie area, 80 miles north of New York City. "The results have exceeded our expectations," says Mallegol.
He notes that the managers of the revenue centers keep sight of the organization’s mission, never pushing revenue initiatives to the point where they would interfere with patient care and support services. (For more about Vassar Brothers’ revenue centers, see "Reverse outsourcing’ fattens hospital’s budget," p. 5.)
Need More Information?
For more on successful outcomes in ambulatory surgery, contact:
- Suzanne Richins, Director of Patient Care, McKay-Dee Hospital, Ogden, UT. E-mail: [email protected].
- Dorothy Jones, Boston College School of Nursing, 140 Commonwealth Ave., Chestnut Hill, MA 92467. Telephone: (617) 552-4058. E-mail: [email protected].
For more on better utilization of fixed assets, contact:
- David Butz, Co-director of the Center for Health Care Economics, University of Michigan Business School, Ann Arbor, MI. E-mail: [email protected].
For more on turning cost centers into revenue centers, contact:
- John Mallegol, Director of Materials Manage-ment, Vassar Brothers Hospital, Poughkeepsie, NY. E-mail: [email protected].
- Richard Henley, Executive Vice President, Health Quest, Vassar Brothers Hospital, 45 Reade Place, Poughkeepsie, NY 12601. Telephone: (845) 431-5607.
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