Applied Science
Lucy Bell
ch.8powerpoint.pptxChapter 8
Hospitals
Introduction (1 of 7)
Inpatient
Overnight stay when the patient is formally admitted with a physician’s order
Outpatient
Services provided while the patient is not staying overnight in a health care institution
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Introduction (2 of 7)
Hospital: An institution with at least six beds and that delivers diagnostic and therapeutic services for medical conditions
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Introduction (3 of 7)
A hospital must:
Be licensed
Have an organized physician staff
Provide continuous nursing service under RNs
Have a governing body that is responsible for hospital conduct
Have a CEO with responsibility for operations
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Introduction (4 of 7)
The hospital must also:
Maintain medical records on each patient
Have pharmacy services available
Provide food services to meet the nutritional and therapeutic requirements of the patients
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Introduction (5 of 7)
Construction and operation of a hospital are governed by:
Federal laws
State health department regulations
City ordinances
JCAHO
Fire codes
Sanitation
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Introduction (6 of 7)
Medical center:
A hospital that has achieved specialization and offers a wide scope of services
Often engages in teaching and research
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Introduction (7 of 7)
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Evolution of the Hospital in the United States (1 of 6)
Stage 1: Before 1850
Only a few hospitals in some major U.S. cities.
Almshouses (or poorhouses), pesthouses: Provided social services rather than health care.
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Evolution of the Hospital in the United States (2 of 6)
Stage 2
Transition from primarily government institutions to community institutions
Supported mainly through private charitable donations
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Evolution of the Hospital in the United States (3 of 6)
Stage 3
Medical discoveries transformed hospitals into institutions of medical practice—a place for medical care and physician training.
Discoveries included:
Anesthesia
Germ theory of disease
X-rays
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Evolution of the Hospital in the United States (4 of 6)
Stage 4
Advanced sanitation, nursing, and medical services.
Well-to-do, private-pay patients started using hospitals.
No longer dependent on charitable contributions as hospitals could generate a profit.
Physician-owned hospitals laid the foundation of proprietary (for-profit) hospitals in the United States.
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Evolution of the Hospital in the United States (5 of 6)
Stage 5
Many hospitals established university affiliations.
Research became an important adjunct to medical care.
Hospitals became complex organizations.
Hospital administration became a discipline in its own right; trained department managers became necessary.
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Evolution of the Hospital in the United States (6 of 6)
Stage 6
Market pressures have prompted hospitals to merge or form affiliations.
Medical systems have formed.
Health systems may include more than one hospital.
They provide a full array of health care services.
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Expansion and Downsizing of the Hospital in the United States (1 of 4)
Number of hospital beds grew significantly between 1872 and 1929:
Coincided with hospitals becoming centers of medical practice.
Technology increased the volume of surgical work.
Professional nursing enhanced patient care.
Additional factors: See Exhibit 8.2.
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Expansion and Downsizing of the Hospital in the United States (2 of 4)
Hill-Burton Act (1946) has been credited with having the greatest impact on hospital expansion.
Creation of Medicare and Medicaid (1965) also fueled demand for hospital services.
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Expansion and Downsizing of the Hospital in the United States (3 of 4)
Hospital downsizing in the United States was triggered by PPS in the 1980s.
Hospitals received a preestablished fixed rate per admission.
PPS necessitated:
Cost cutting
Quicker discharge of patients
Many hospitals across the country had to close.
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Expansion and Downsizing of the Hospital in the United States (4 of 4)
In the 1990s, managed care curtailed inpatient utilization.
Managed care emphasized:
Early discharge
Outpatient services
PPS and managed care had the desired effect of reducing growth of hospital expenditures.
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Access and Utilization Measures (1 of 5)
Measures of access
Discharges: Total number of patients released from a hospital’s acute care beds during a given period
Discharges per 1,000 population: An indicator of level of access to hospital inpatient services
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Access and Utilization Measures (2 of 5)
Measures of utilization
Inpatient day: A night spent in the hospital by a patient
Average length of stay (ALOS): Average number of days a patient spends in the hospital
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Access and Utilization Measures (3 of 5)
Days of care: Total number of inpatient days incurred by a population over a given period of time
Days of care = discharges × ALOS
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Access and Utilization Measures (4 of 5)
Elderly spend more time in hospitals than do younger people.
Women are admitted to hospitals more often than men, but men incur longer stays.
Hospital utilization is higher among blacks than whites.
Utilization is higher among the poor than the nonpoor.
Overall hospital utilization is higher among Medicare and Medicaid recipients.
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Access and Utilization Measures (5 of 5)
ALOS in the United States is 4.8 days.
Sharp declines in ALOS became possible with the growth of alternative services (home health, subacute long-term care).
No evidence that quicker discharge from hospitals harmed patients.
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Utilization of Hospital Capacity (1 of 3)
Capacity
The number of beds set up, staffed, and made available by a hospital for inpatient use.
84% of community hospitals in the United States have fewer than 300 beds.
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Utilization of Hospital Capacity (2 of 3)
Census: Number of patients on a given day
Patient days or days of care = Cumulative census
Average daily census = Patient days in a given period ÷ days in that period
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Utilization of Hospital Capacity (3 of 3)
Occupancy rate
The percentage of capacity utilized during a defined period of time
Derived by dividing the average daily census for that period by the capacity
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Hospital Employment
19.6 million workers are employed in the health care and social assistance sector.
26% of health care workers are employed in hospitals.
Growth in the outpatient sector exceeds that in hospitals.
Hospitals are expected to see the lowest job growth compared to other sectors of the health care industry.
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Types of Hospitals (1 of 19)
Figure 8.3 Types of Hospitals, 2016
Data from Health Forum LLC, an affiliate of the American Hospital Association. Fast facts on U.S. hospitals. 2018. https://www.aha.org/system/files/2018-
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Types of Hospitals (2 of 19)
Community hospitals
A nonfederal short-stay hospital whose services are available to the general public.
More than 87% of hospitals are community hospitals.
Characteristics: See Exhibit 8.4.
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Types of Hospitals (3 of 19)
Public hospitals
Government ownership (federal, state, or local).
One-fourth of U.S. hospitals.
Only state/local hospitals are open to the general public.
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Types of Hospitals (4 of 19)
Public hospitals (cont’d)
Often located in large urban areas.
Serve mainly inner-city indigent and disadvantaged populations.
Have higher utilization.
Offer a substantial amount of charity care.
Number of hospitals owned by state and local governments has declined.
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Types of Hospitals (5 of 19)
Private nonprofit hospitals
Called voluntary hospitals
Nongovernment and privately owned
Make a profit but do not pay taxes
Operated by:
Community associations
Churches
Other nongovernment organizations
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Types of Hospitals (6 of 19)
Private nonprofit hospitals (cont’d)
More than 50% of all U.S. hospitals are private nonprofit.
IRS requirements:
Must provide some defined public good: Service, education, community welfare.
Cannot distribute profits to any individual.
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Types of Hospitals (7 of 19)
Private nonprofit hospitals (cont’d)
Research shows that both nonprofit and for-profit hospitals provide charity care.
Nonprofits spend a little more on charity care, but the difference is small.
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Types of Hospitals (8 of 19)
Private for-profit hospitals
Proprietary hospitals
Also referred to as investor-owned hospitals
Are owned by individuals, partnerships, or corporations for profit
Operated for financial benefit of stockholders
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Types of Hospitals (9 of 19)
General hospitals
Most hospitals in the United States are general.
Provide a broad set of services for various conditions.
General and specialized medical care:
Obstetrics
Diagnostics
Treatment
Surgery
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Types of Hospitals (10 of 19)
General hospitals (cont’d)
General hospitals are not less specialized or inferior to specialty hospitals.
Difference is the nature of services, not quality.
Specialty hospitals focus on a narrow range of services for specific conditions or patients.
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Types of Hospitals (11 of 19)
Specialty hospitals
Include psychiatric, rehabilitation, tuberculosis, children’s hospitals, etc.
Others specialize in orthopedic surgery, cardiology, or cancer
Have a distinct service niche
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Types of Hospitals (12 of 19)
Psychiatric hospitals
Provide diagnostic and treatment services for patients who have mental illnesses.
Must have facilities to provide psychiatric, psychological, and social work services.
Must have a written agreement with a general hospital for the transfer of patients.
Most mental health services are delivered in private psychiatric facilities and outpatient treatment centers.
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Types of Hospitals (13 of 19)
Rehabilitation hospitals
Provide intensive therapeutic services to restore maximum function
Types of patients include amputees and those with spinal cord or head injuries.
Accident or sport injuries
Stroke victims
Treatment usually after orthopedic surgery
Provide PT, OT, speech, and language pathology
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Types of Hospitals (14 of 19)
Children’s hospitals
Community hospitals
Treat chronic, congenital cardiac, and orthopedic pediatric problems
Intensive care for a variety of conditions, such as cancer, cystic fibrosis, tissue transplants
Higher staffing ratios than in general hospitals
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Types of Hospitals (15 of 19)
Rural hospitals
Located in a county that is not part of a metropolitan statistical area (MSA)
Generally treat a larger percentage of poor and elderly patients
Often find themselves in financial trouble and face closure
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Types of Hospitals (16 of 19)
Rural hospitals (cont’d)
Critical access hospitals (CAHs): Medicare designation for a rural hospital that:
Has 25 or fewer beds.
Provides 24-hour emergency care.
CAHs are reimbursed according to the retrospective cost-plus method, not PPS.
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Types of Hospitals (17 of 19)
Teaching hospitals
Offer one or more graduate residency programs approved by the American Medical Association.
Primary role is to train physicians.
Major teaching hospitals are affiliated with universities.
Have substantial teaching and research mission.
Deliver specialized care for many complex conditions.
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Types of Hospitals (18 of 19)
Teaching hospitals (cont’d)
Academic medical centers have active collaboration among a university, medical school, hospital/health system, and health care professionals.
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Types of Hospitals (19 of 19)
Osteopathic hospitals
Community general hospitals.
Holistic approach to treatment, in addition to traditional allopathic approach.
Since the 1970s, allopaths and osteopaths have been practicing side by side.
Many of these hospitals have closed because separate hospitals have become unnecessary.
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Licensure, Certification, and Accreditation (1 of 3)
Licensure
Required in order to operate a hospital
State government (state departments of health) oversees with own set of standards
Emphasizes physical plant compliance with:
Building codes
Fire safety
Climate control
Space allocations
Sanitation
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Licensure, Certification, and Accreditation (2 of 3)
Certification
Allows a hospital to participate in Medicare and Medicaid.
Compliance with federal “Conditions of Participation” is necessary.
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Licensure, Certification, and Accreditation (3 of 3)
Accreditation
The Joint Commission accredits a variety of health care facilities.
A private nonprofit organization.
Accreditation confers deemed status on hospitals.
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Hospital Organization (1 of 2)
A hospital is generally responsible to stakeholders such as:
The community
Government
Insurers
Managed care organizations
Accreditation agencies
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Hospital Organization (2 of 2)
Internally, hospital governance involves three major sources of power:
Board of trustees: Governing body, board of directors
CEO: Receives delegated authority from the board and is responsible for managing the organization with the help of senior executives
Medical staff
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Ethics and Public Trust
Most significant ethical issues occur in acute care hospitals
Factors:
Advanced technologies
Constraints on reimbursement
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Ethical Challenges
Physicians and caregivers are guided by the principles of:
Beneficence: Alleviate suffering
Nonmaleficence: A moral obligation to not harm patients
Differences of opinion on what constitutes extraordinary or heroic measures to sustain a person’s life
Addressing Ethical Issues (1 of 4)
Ethics committees
Charged with developing guidelines and standards for ethical decision-making in the provision of health care
Interdisciplinary, involving physicians, nurses, clergy, social workers, legal experts, ethicists, and administrators
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Addressing Ethical Issues (2 of 4)
The Patient Self-Determination Act of 1990
Applies to all health care facilities participating in Medicare or Medicaid.
The law requires health care facilities to provide all patients, on admission, with information on patients’ rights.
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Addressing Ethical Issues (3 of 4)
Informed consent
A basic patient right
Right to make an informed choice regarding medical treatment, including the right to refuse treatment
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Addressing Ethical Issues (4 of 4)
Advance Directives
Patient’s wishes regarding continuation or withdrawal of treatment when patient lacks decision-making capacity
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Public Trust
Hospital administrators have a fiduciary responsibility for acting prudently in managing the organization.
The hospital should be viewed as a community asset.
When such a viewpoint is lost, a breach of public trust can occur.
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Conclusion (1 of 2)
Any facility that treats patients on the basis of an overnight stay is called an inpatient facility.
The most common types of inpatient facilities are hospitals and nursing homes; both trace their beginnings to almshouses and pesthouses.
Both expansion and contraction of hospitals were triggered mainly by government policy.
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Conclusion (2 of 2)
Severe restrictions on the expansion of physician-owned hospitals.
The majority of hospitals in the United States are community hospitals.
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