EL: That is absolutely correct. Moreover, I would say that’s not an intervention. That is the intervention. We have only two options. The first option is to provide excessive resources to staff at the peak level, which no hospital in the world has resources to do. The other choice is to staff below the peak level, a pivotal way of staffing hospital wards today. Typically, we staff them at the average level that has been documented historically from the last year. About 10 years ago, we received a grant from the Robert Wood Johnson Foundation to study two community and two academic hospitals, and we found that ward bed occupancies changed every hour, if not every half hour. There is absolutely no way that one may have a pool of nurses dynamic enough to address heavy peak volumes because nurses do not live in the hallway to address every hour or half-hour change in the census.
Explore This IssueACEP Now: Vol 35 – No 11 – November 2016
PV: In the places where you helped to implement smoothing of the elective schedule, what was the end result?
EL: The end result was huge, both financial and quality wise at every hospital. Cincinnati Children’s is probably one of the most impressive examples. When we started working with them on smoothing, their census was at the 76 percent level. In order to address peaks, they planned to build a new tower for $100 million in capital costs. Each bed in the United States, in terms of the capital cost, varies from $1.5 million to $3 million in capital cost alone. Plus, the annual operational cost per bed is at least half a million dollars. At the end of our smoothing project, they abandoned their plan to build the new tower. The average census reached 91 percent, a 15 percent increase. Their surgical volume increased dramatically without capacity issues because when we cut off the peak, we filled up the valley. It’s not just the peaks that create quality consequences; when we have those valleys, that’s a waste of our resources. Their surgical volume dramatically increased, and according to their report, their margin improved by over $100 million a year. It’s not just $100 million in avoided capital cost; it’s an additional over $100 million a year margin improvement and quality improvement.
PV: I understand that hospitals had had significant problems with boarding in the emergency department that also disappeared as soon as they smoothed their capacity.
November 29, 2016Kurt Knochel
On October 18, 2016 Cincinnati Children’s hospital board of trustees approved construction to increase beds by 33%. Here is link: http://www.cincinnati.com/story/news/2016/11/10/cincinnati-childrens-boost-beds-33/93598474/
This directly contradicts the interview.
December 8, 2016Eugene Litvak, PhD
The following three links contain the relevant data:
1. “Improvements in efficiency have boosted our capacity by the equivalent of a $100 million, 100-bed expansion and increased income from treatment of patients by even more” at http://www.jointcommissioninternational.org/assets/1/14/MPF09_Sample_Chapter.pdf (PDF,
2. “No waiting: A simple prescription that could dramatically improve hospitals — and American health care” at http://www.boston.com/bostonglobe/ideas/articles/2009/08/30/a_simple_change_could_dramatically_improve_hospitals_ndash_and_american_health_care
3. “James Anderson, adviser to the president at Cincinnati Children’s Hospital, said IHO helped that hospital improve revenues by 34 percent and avoid spending $100 million on a planned patient tower it no longer needed. Anderson, the hospital’s former president and CEO, said waiting times in the ER and OR also dropped.” Available at ttp://www.chicagotribune.com/lifestyles/health/sc-eugene-litvak-health-0504-20160502-story.html
As you can see from the above materials, these changes have been implemented 10 years ago and saved $100 million in avoided capital cost alone. I would assume patient volume increased since then. I would be unreasonable to state that this (or any other) intervention eliminates bed needs FOREVER.