Reducing the length of stay for acute hospital patients needing admission into inpatient rehabilitation: a multicentre study of process barriers.

BACKGROUND: Patient flow is a major problem in hospitals. Delays in accessing inpatient rehabilitation have not been well studied. AIMS: Measure the time taken for key processes in the patient journey from acute hospital admission through to inpatient rehabilitation admission in order to identify opportunities for improvement. METHODS: Retrospective open cohort study. All patients admitted over 8- and 10-month periods during 2008 into two inpatient rehabilitation units in Melbourne, Australia. Main outcome measures were the duration of the following key processes: acute hospital admission until referral for rehabilitation, referral until assessment by the rehabilitation service, assessment until deemed ready for transfer to rehabilitation, ready for transfer until rehabilitation admission. RESULTS: Three hundred and sixty patients were in the study sample (females = 186; 51.7%); mean age = 58.4 (standard deviation = 15.0) years. There was a median of 7 (interquartile range [IQR] 4-13) days from acute hospital admission till referral for rehabilitation, a median of 1 (IQR 0-1) day from referral till assessment, a median of 0 (IQR 0-2) days from assessment till deemed ready for transfer and a median of 1 (IQR 0-3) day from ready till admission into rehabilitation. Overall, patients spent 12.0% (804/6682) of their acute hospital admission waiting for a rehabilitation bed. CONCLUSIONS: There are opportunities to improve the efficiency of key processes in the acute hospital journey for patients subsequently admitted to inpatient rehabilitation; in particular, reducing the time from acute hospital admission till referral for rehabilitation and from being deemed ready for transfer to rehabilitation till admission.

Why older patients of lower clinical urgency choose to attend the emergency department.

BACKGROUND/AIMS: To examine non-clinical factors associated with emergency department (ED) attendance by lower urgency older patients. METHODS: An exploratory descriptive study comprising structured interviews with lower urgency community-dwelling patients aged ≥70 years presenting to a tertiary metropolitan Melbourne public hospital ED. Demographical and clinical characteristics, self-reported feelings of social connectedness, perceived accessibility to primary care, reason for attending ED were measured. RESULTS: One hundred patients were interviewed: mean age 82 years, 56% female, 57% lived alone; 73% presented during business hours, 58% arrived by ambulance, 80% presented for illness, and 65% were discharged home within 48 h. Fifty-six per cent of patients reported feeling socially disconnected, comprising 49% living alone compared with 65% who lived with their spouse/family. All patients attended a regular general practitioner, 31% reporting regular review appointments. Thirty-five per cent reported waiting times >2-3 days for urgent problems; 59% stated accessing care 'after hours' without attending ED as difficult, with 20% having attended ED 3-6 times in the previous 12 months. Reasons for attending ED were referral by a third party, difficulty with accessibility to primary care, patient preferences for timely care and fast-track access to specialist care. CONCLUSIONS: Most older patients of lower clinical urgency presented to ED because of perceived access block to primary or specialist services, alongside an expectation of more timely and specialised care. This suggests that EDs should be redesigned and/or integrated community-based models of care developed to meet the specific needs of this age group who have growing demand for acute care.

EBM in healthcare: management and policy.

The nature of policymaking often precludes a significant role for formal evidence-based practice. Management practice is also bereft of formal evidence and appears unlikely to change because of the methodological constraints on collecting good evidence. Despite this, policymakers and managers are keen to promote evidence-based clinical practice. This, in part, reflects rational management's desire to standardise the clinical process and develop the profession's accountability to the management hierarchy. To the extent that clinical practice is dependent on organisational settings, this push is inevitable. Widespread and persistent small-area variation in clinical practice, and concern over apparent high levels of avoidable error, make doctors vulnerable to these efforts to standardise clinical practice.

Casemix payment in the real world of running a hospital.

The Victorian casemix funding initiative has achieved initial success in implementing massive budget cuts while increasing hospital throughput and reducing waiting lists. For hospitals to survive, the relationship between casemix and resource use must be managed and this can only be achieved by the involvement of clinicians. With effective information systems and accommodating clinicians, games to maximise casemix, and hence revenue, will undoubtedly emerge. Side effects may include reduced access to "unprofitable" services, increasing pressure on "unprofitable" clinicians and the wooing of "profitable" ones, increasing difficulty in delivering continuity of care and the politicisation of the diagnosis-related groups pricing system. In the end, State governments will be left with a complex control system without resolving the fundamental dilemma inherent in being both the provider of hospital care and the payer.

Drug and therapeutics committees: the relationships among structure, function, and effectiveness.

Reported are the results of a national study of Australian hospitals that assessed the effectiveness of drug and therapeutics committees (DTCs), identifies factors that influence effectiveness, and recommends methods to improve effectiveness. Data were collected by questionnaires sent to 184 hospital directors of pharmacy and a subset of 53 chairpersons of DTCs. Response rates were 88.6% and 84.9%, respectively. Membership, chairperson, secretary, meeting frequency, and decision-making functions were analysed by hospital bed numbers and compared with standard accepted literature criteria and previous study findings. A comparison of pharmacist and chairperson perception as to the weakest aspect of DTCs in attaining rational therapy revealed widely differing views, based on factors outside respondents' own control. Perceptions of resources required to overcome DTC weakness also varied between the two groups. No statistically significant association was found between the assessment of outcome of DTC activities (influence on pharmacy management, hospital policy, medical management, and prescribing) and structural variables such as DTC objectives, chairperson, reporting relationship, meeting frequency, and hospital size or type. The results challenge widely held assumptions of the association between DTC effectiveness and structural variables. Further study of structural and cultural variables, which might determine effectiveness, is required.

The design and implementation of a management information system for Australian public hospitals.

Existing management information systems (MIS) in hospitals are often inadequate. This has occurred because of a variety of antecedents, including past funding mechanisms, organisational structure and the accepted role of management. A variety of new pressures, including demands for increased accountability, greater resource control and changing relationships between physicians and hospitals are demanding improved MIS to enable the hospital to manage. This paper explores these influences on past and future hospital MIS. It describes the design of a MIS that enables patient care to be costed in clinically meaningful ways. Patient costs may be aggregated to cost specific diagnoses and procedures, Diagnosis Related Groups (DRG), a clinician's case load, a clinical unit or a division. The information can be used for clinical budgeting, flexible budgeting, utilisation review and quality assurance.

Models for costing patient care services. Part 2: Costing organ imaging services.

This is the second of a series of articles describing the cost models developed as part of the new computerised Clinical Information System (CIS) at the Queen Victoria Medical Centre campus of the Monash Medical Center in Melbourne. The first article in this series described the costing of diagnostic laboratory services. This paper provides a brief overview of the CIS and describes the costing of services in the Medical Imaging Division.

Nurse managers and budgeting: professional/bureaucratic conflict?

Professional/bureaucratic conflict theory suggests that the extent to which nurse managers use management control systems will depend on whether their goal orientation is to system rather than output or derived goals. This article examines the use of budgeting as a management control strategy, in relation to the goal orientation of nurse managers, in four large teaching hospitals. The goal orientations and use of budgeting by nurse managers is also compared with those of physician managers and other sub-unit managers. The results indicate that nurse managers appear to be developing their goals of professionalization without a diminution of their organizational focus or their orientation towards providing a high standard of patient care.

Improving patient care and pharmacy management: the effect of hospital formularies.

A study of the organizational features and implementation procedures associated with formulary use in major acute-care hospitals throughout Australia was undertaken. Data were collected via a questionnaire mailed to 57 directors of pharmacy. An 86-percent response was obtained. A high proportion of formularies was found to rate poorly in terms of organizational features (e.g., content, compilation methods, format) and process variables (e.g., effectiveness as a communication document, prescribing aid, or management tool). Methods of improving formulary effectiveness are outlined in the context of practical and normative research, including improving the quality of drug therapy, use of formularies in cost control, and improving user acceptance. The results confirm previous research showing that methods of improving organizational features and implementation procedures associated with formulary compilation and use are neither widely applied nor widely known. There is an urgent need to reassess the usefulness of formularies and improve their effectiveness by adopting recommendations resulting from past research.

Hospital social work: cui bono?

The role of hospital social work departments (SWDs) is often the subject of dispute. Medical administrators, who hold the purse and policy strings, and heads of SWDs will have a major influence on the evolution of these departments in times of continued financial constraint. Their views on the importance of the services provided by the SWD, both currently and in the future, were canvassed by mailing a questionnaire to all teaching hospitals in Australia. A 90% overall response was achieved. In general, instrumental tasks (those associated with the traditional "almoner" role) were perceived by medical administrators and heads of SWDs as of equal importance. Independent professional social work activities and social change agent services were more highly valued by heads of SWDs. Most services were expected to increase, with only "placement" declining in the future. More change was expected by heads of SWDs than by medical administrators. These results are seen to reflect the differing values of the two groups, the significance of which is discussed.