Too Much Construction?

When a new emergency department opened at St. Joseph Medical Center, doubling the bed count to 40, most staffers at the Towson, Md., hospital expected ambulance diversions and long patient waits to go away.

They were disappointed.

“After the last construction phase opened, it took a month or two to realize that, ‘Gee, nothing is getting better,’” says emergency room physician Joseph Twanmoh, M.D. In fact, ambulance diversion hours hit a record of 287 in December 2003, three months after the big new ED opened, while patients languished in the lobby for hours before being treated.

Today those problems are history—not because more beds were added, but because St. Joseph changed the way patients move through the ED and other hospital units. As Carol Haraden, Ph.D., would say, St. Joseph improved its patient flow. For the past four years, Haraden, vice president at the Institute for Healthcare Improvement, a nonprofit organization headquartered in Cambridge, Mass., has been studying how patients move—or, more accurately, how patients are delayed as they lurch through the healthcare system. “Across the country, almost nobody has what we would call ‘good flow,’ in which the patient moves seamlessly, without delays, from one place to the other,” she says.

Instead, patients who need an intensive care bed may wait in the ED for one to clear, for example, while ICU beds are occupied by patients ready to move to a medical-surgical floor. “Why can’t they move? Because discharges are delayed or because patients in that med-surg unit are waiting for long-term care beds or rehab beds,” Haraden says.

In working on patient flow issues with nearly 80 hospitals, Haraden has come to believe that the typical American hospital is plagued with wasted capacity. Beds aren’t necessarily sitting empty, but the ability to treat patients is constrained by the inefficient use of resources. In her view, the nation’s no-end-in-sight healthcare building boom may be the wrong solution for a misunderstood problem.

“If all we do is build new beds and we keep the same systems that created the overcrowding, we really have no expectation that the situation is going to change,” Haraden says.

The hospital industry has spent nearly $100 billion on new facilities in the past five years, with 2005 being the biggest hospital construction year ever, according to the Census Bureau. Helen Darling, president of the nonprofit Washington, D.C.-based National Business Group on Health, believes that while a few communities may need more beds, most of the construction cranes swinging over healthcare campuses are on a misguided mission. If hospitals redeployed construction dollars to other tasks—such as reducing medication errors—patients would spend less time in the hospital, she contends.

That said, Darling understands why the building boom continues. For one reason, it’s easier to raise money for a new hospital wing than for the technology and training that would reduce medication errors. For another, the quirky way hospitals are paid encourages new capacity. Cardiac procedures, for example, are generally profitable, but treating uninsured patients for chronic conditions is not—a reality that encourages hospital executives to add cardiac-care capacity as a way of funding their mission.

Additionally, executives must consider market share and customer mix. After the state certificate-of-need agency turned down its request to build a new hospital, Saint Luke’s Health System in Kansas City, Mo., waged a court battle to expand into a fast-growing suburb. The new hospital, which opened in January, gives the 11-hospital system access to a large commercially insured population while its flagship hospital serves a growing number of uninsured residents in the urban core.

“We became convinced that financially it was a beneficial project for us, but also there was a need in the suburb that was going unmet,” says Chuck Robb, chief financial officer. “That community had a strong preference for Saint Luke’s services, and we have been basically filled to capacity since the day we opened.”

Saint Luke’s process-improvement bona fides are in good condition: The system’s main hospital received one of the first Malcolm Baldrige National Quality Awards in the healthcare category, and the new hospital is an all-digital pioneer. But St. Joseph’s Twanmoh, assistant professor of emergency medicine at the University of Maryland School of Medicine, says many hospitals add beds because process problems masquerade as capacity problems.

Twanmoh was a new ED staff member at St. Joseph Medical Center when he and his ED colleagues revamped triage and admission processes as part of a hospitalwide initiative to improve patient flow and maximize capacity. They changed the layout of the urgent care area and modified staffing patterns to match patient volume. They also began flagging charts of patients ready for discharge and implemented admission orders to decrease patient wait times.

“Too often people don’t want to deal with basically re-engineering the old process because there’s just not a lot of glamour in it,” he says.

Lola Butcher is a Springfield, Mo.-based freelance writer and a frequent contributor to HealthLeaders magazine.