Lecture 8/Chapter 8 Flashcards
1
Q
inpatient
A
-requires an overnight stay in a health care facility
2
Q
hospital
A
- an institution with at least 6 beds
- function is to deliver patient services that include diagnostic and treatment
- evolved from institution of refuge for homeless and poor
- ultramodern facilities providing advanced services
- must be licensed
- have an organized physician staff
- provide continuous nursing services supervised by RNs
3
Q
hospital characteristics
A
- a governing body is legally responsible for hospital conduct -> board of directors
- a CEO is responsible for operations
- medical records on each patient
- pharmacy services supervised by a registered pharmacist
- food services to meet nutritional needs
4
Q
construction and operation of a hospital are governed by:
A
- federal laws
- state health regulations
- city ordinances
- *joint commission standards -> makes recommendations if the hospital meets certain standards or performance, cleanliness -> carries huge wait for medicare and medicaid reimbursement
- fire codes
- sanitation standards
5
Q
inpatient costs
A
- hospitals consume the biggest share of national health spending
- were the first to be targeted with prospective payment systems (PPS)
- subsequently, outpatient services mushroomed
6
Q
social welfare
A
-almshouses and pesthouses
7
Q
care for the sick
A
-public and voluntary (charitable) institutions
8
Q
evolution of five dominant functions in hospital transformation
A
- social welfare
- care for the sick
- medical practice
- medical training and research
- consolidated systems
9
Q
medical practice
A
- medical science and technology
- hospital administration, organization, efficiency
- the joint commission
10
Q
medical training and research
A
-collaboration between hospitals and universitites
11
Q
consolidated systems
A
- organizational integration
- service diversification
- hospital/heatlhcare systems*
12
Q
expansion phase: development of professional nursing
A
- florence nightingale transofmred nursing
- efficiency of treatmnet; hygeine
13
Q
expansion phase: growth of health insurance
A
- great depression closed many hospitals
- insurance allowed people to pay for health care
- increased the demand for health care
14
Q
expansion phase: role of government
A
- *hospital survey and construction act (hill burton act, 1946):
- federal grants to build nonprofit community hospitals
- charitable care was a condition
- biggest factor to increase nations bed supply
- by 1980, goal of 4.5 beds per 1,000 population reached
- *public health insurance (medicare and medicaid)
15
Q
downsizing phase: mid 1980s onward
A
- average hospital has become smaller
- shift from inpatient to outpatient
- changes in reimbursement- from cost-plus to PSS and decrease in inpatient utilization
- impact of managed care
- hospital closures- since 2000 many government run hospitals closed
16
Q
downsizing phase: impact of managed care
A
- emphasis on cost containment
- efficient utilization of resources (care in alternative settings)
17
Q
downsizing phase: hospital closures
A
- economic constraints
- many rural and urban hospitals had to close
- other hospitals closed wings or used them for alternative purposes
18
Q
utilization measures and operational concepts: discharges
A
- discharges per 1,000 population
- an indicator of access and utilization
- number of overnight patients a hospital serves in a given time period
- includes newborns and deaths
19
Q
hospital transformation in the US
A
five functions in the evolution of hospitals:
- primitive institutions of social welfare
- distinct institutions of care for the sick
- organized institutions of medical practice
- advanced medical training and research
- consolidated systems of health services delivery
20
Q
utilization measures and operational concepts: inpatient day (patient day)
A
-a night spent by a patient
21
Q
average length of stay (ALOS)
A
- days of care/discharges
- an indicator of severity of illness and resource use
- highest in federal hospitals, followed by stated and local government hospitals
- private nonprofit and for profit hospitals had the same ALOS in 2010
22
Q
capacity
A
- size is determined by number of beds set up and staffed
- 84% of community hospitals in US have fewer than 300 beds
- average size of community hospital is 161 beds
23
Q
average daily census
A
- average number of beds occupied per day
- days of care/number of days
- if it is low they dont get approved for a lot of beds
24
Q
occupancy rate**
A
- percent of capacity occupied
- calculation: average daily census / number of available beds (capacity) x 100
- a measure of performance
25
higher utilization among
- the elderly
- children under 1
- women
- people of lower socio-economic status (bc they dont have primary care)
- medicare and medicaid beneficiaries
26
expansion phase
- development of professional nursing
- growth of private health insurance
- role of government- hill burton act and public health insurance
27
key utilization measure and operational concepts
discharges
- inpatient days
- average length of stay- hospital access and utilization -> comparative data
- capacity
- average daily census
- occupancy rate
28
factors that affect hospital employment
- Hospitals accounted for largest number of jobs in the health care industry in 2013.
- Workforce represented roughly 39% of total health care employment.
- More than 6 million people are employed by U.S. hospitals.
- Changes in reimbursement policy can affect employment.
- Cannot outsource health care jobs because they generally require personal interaction.
29
hospital employment
- 4% of all service jobs
- employment has continued to grow
- 2005- 4,350,000
- 2009- 4,680,000
- SBUH- 5,100 employees- largest single site employer in suffolk county
- north short-LIJ system- 31,000 employees -> 31 hospitals and 5,678 beds
30
hospital costs
- inpatient hospital services are the largest share of total US health care expenditures
- medicare and medicaid payments
- rise in bad debts
- international cost comparison
31
types of hospitals
```
Classification by ownership:
-public hospitals
-private nonprofit hospitals
-private for-profit hospitals
Classification by public access
Classification by multiunit affiliation
Classification by type of service:
-general hospitals
-specialty hospitals
-physician-owned specialty hospitals
-psychiatric hospitals
-rehabilitation hospitals
-childrens hospitals
Classification by length of stay:
-short stay hospitals
-long term care hospitals
Classification by location
-swing bed hospitals
-critical access hospitals
-other rural designations
Classification by size
-other types of hospitals:
-teaching hospitals
-church affiliated hospitals
-osteopathic hospitals
```
32
public hospitals
- first appear when almhouses and pesthouses evolved into hospitals
- owned by federal, state, or local government
- federal hospitals are open to special groups only (NA, military, veterans)
- VA runs the largest hospital system (federal)
- states run mainly psychiatric hospitals
- local hospitals (county or city owned) serve a high proportion of disadvantaged groups
- overall high utilization*
- average length of stay (ALOS) highest in federal hospitals -> veteran population is aging
33
private nonprofit hospitals
- owned and operated by community associations or other nongovernment organizations
- their mission is to benefit the community
- largest group of hospitals*
- does NOT mean that they do not make money !!!
- ex. northshore
- they do not give profits to shareholder
- reinvests money into organization to make it better
34
private for profit hospitals
- operated for the financial benefit of owners or stockholders
- have gained market share, mainly as physician owned specialty hospitals have grown in number
- lower occupancy rates than nonprofits
35
expectation for nonprofit hospitals
- internal revenue code, section 501
- grants tax-exempt status to nonprofit organizations
- institutions are exempt from federal, state, and local taxes
- nonprofit organizations provide some defined public good and do not distribute any profits to any individuals
36
community hospitals
- nonfederal
- short stay
- serve the general public
- can be proprietary, voluntary or government owned (only state or local)
- can be a general or specialty hospital
- 87% of US hospitals are community hospitals
37
noncommunity hospitals
- federal hospitals
- hospital units of institutions (prisons, colleges)
- long term stay
38
multiunit affiliation hospitals
- 2 or more hospitals (owned/leased/managed)
- 2011- 61% of hospitals were affiliated with a multihospital system (52% in 2005)
- nonprofit chains dominate
- advantages:
- economies of scale
- wide spectrum of care; variety of markets
- access to capital
- ease of contracting with managed care
- access to management resources and expertise
39
nonprofit organization
- provide some defined public good
| - do not distribute any profits to any individual
40
nonprofit institutions face new ACA demands
- 1. establish written financial assistance and emergency care policies
- 2. limit charges for those eligible for assistance under hospitals financial assistance policy
- 3. limit billing and collection actions against those within the guidelines of financial assistance
- 4. conduct a community health needs assessment
41
some management concepts
- hospitals organizational structure differs from other large business organizations
- hospital governance:
- board of trustees
- chief executive officer
- medical staff
42
short stay hospitals
- high level care until they can move you
- ALOS of 25 days or less
- treat acute conditions
43
swing bed hospital
- rural areas
| - flexibility to shift -> more flexibility with types of bed used
44
urban hospitals
- located in a metropolitan statistical area (MSA)
| - have higher costs: high salaries, competition, broader and complex services
45
rural hospitals
- not in a MSA
| - 40% of all community hospitals
46
balanced budget act 1997
- managing the money
- to save small rural hospitals from closure
- maximum 23 acute care or swing beds
- emergency services must be available
- must meet a distance test
- can have 10-bed psychiatric unit, a 10-bed rehabilitation unit, and a SNF
- cost-plus reimbursement, not to exceed 101% of cost
47
community hospitals by size: most popular
- 25-99 beds
| - 43.1%
48
teaching hospitals
- medical training and research
- additional reimbursement from medicare
- broad and complex scope of services (often have tertiary care services)
- many located in economically depressed areas -> they dont have choice of where they go for care
- provide disproportionate share of uncompensated care
- COTH members provide nearly half of charity care nationwide
49
church affiliated hospital
- charity based
- first established by catholic sisterhoods
- mostly community general hospitals
- owned or influenced by church groups
- do not discriminate in giving care
- spiritual and dietary emphases are often present
50
osteopathic hospitals
- till about 1970, osteopaths operated their own hospitals
- subsequent acceptance by allopathic practitioners
- separate osteopathic hospitals are no longer needed -> they are also more costly and less productive
- many have closed
51
licensure, certification, and accrediation
- state government oversee the licensure of health care facilities
- certification allows a hospital to participate in medicare and medicaid programs
- accreditation is designed to ensure facilities meet certain basic standards
52
magnet recognition program
- designation conferred by the american nurses credentialing center
- affiliate of the american nurses association
- evaluates nursing staff
- recognizes-
- quality patient care
- nursing excellence
- innovation in professional nursing practice in hospitals
53
management concepts
- hospital governance: a tripartite structure
- board of trustees- governing body, board of directors
- CEO- administrator / president
- medical staff- chief of staff heads the medical staff
54
licensure*
-a hospital must be licensed to operate
-state government oversees with own set of standards
-emphasizes physical plant compliance with:
-building codes
-fire safety
-
55
certification
- not mandatory (required only if hospital wants to participate in medicare and medicaid- most do)
- a federal function
- hospitals must comply with the conditions of participation -> federal standards for health, safety, and quality
- currently revised conditions focus on quality of care delivered and the outcomes of that care
56
accreditation
- joint commission or american osteopathic association
- accreditation is a private undertaking
- it is voluntary for the hospital
- it confers deemed status on hospitals
- deemed status is not conferred on nursing homes
- how you get paid
- stamp of approval
57
ethical and legal issues in patient care**
- principles of ethics
- legal rights
- mechanisms for ethical decision making
58
respect for others
- autonomy- empowerment
- truth telling- honesty
- confidentiality- privacy
- fidelity- duty and promises
59
beneficence
-benefit to the patient
60
nonmalficence
- do no harm
| - benefits > potential harm
61
legal rights
- challenges arise in treating incompetent and comatose patients
- patient self determination act of 1990
- inform patients of their rights upon admission
- bill of rights and informed consent
- advance directives - DNR, living will, durable power of attorney
- main rights:
- confidentiality
- consent re: medical care
- information on diagnosis and treatment
- right to refuse treatment
- formulation of advance directives
62
informed consent
- right to make an informed choice regarding medical treatment
- right to obtain complete current information on diagnosis, treatment, and prognosis
- patient centered care- organizational culture that promotes patient involvement, respects preferences, solicits patients inputs, and furnishes needed information and education
63
advance directives
- patients wishes regarding continuation or withdrawal of treatment when patient lacks capacity to make end of life decisions
- 3 types:
- 1. do not resuscitate (DNR) -> no CPR
- 2. living will- patients wishes are indicated in advance
- main drawback- limited in scope
- 3. durable power of attorney:
- patient appoints someone else to make decisions
- main drawbacks- patients wishes may be bypasses
64
ethics committees
- develop guidelines and standards
- address ethics issues
- multidisciplinary
65
moral agent
- health care managers
- moral responsibility to put patients needs above those of the organization
- ethics transcends compliance with the law
66
summary
- almshouses and pesthouses evolved into public hospitals to serve the poor
- key measures of inpatient utilization
- hospitals are classified in numerous ways
- ACA restrictions
- ethical decisions making has been a special area of concern for hospitals
67
downsizing phase: changes in reimbursement
- from cost-plus to PPS
| - decrease in inpatient utilization
68
utilization measures and operational concepts: days of care
-cumulative patient days over a time period
69
long stay hospitals
- ALOS > 25 days
- psychiatric
- LTCHs
- chronic care
70
LTCHs
- must meet medicare guidelines
- patients with complex medical needs
- rapid growth has occurred
71
elderly/poor disparities
-inner city urban and rural hospitals treat poor and elderly disproportionately
72
board of trustees
- legally responsible for operations
- establish mission and long term direction
- evaluate major decisions and approve plans and budgets
- monitor performance
- appoint and evaluate the CEO
- approve appointment of medical staff
- committees (e.g. executive commitee, medical staff committee)
73
chief executive officer (CEO)
- carry out the mission and objectives
- responsible for day to day operations
- leadership
- receives delegated authority from the board
- answers to the board of trustees
74
medical staff
- accountable to the board
- physicians are formally granted admitting privileges
- chief of staff (medical director)
- chiefs of service (for specialties) in major hospitals
- committees: executive, credentials, medical records, utilization review, infection control, quality improvement
75
licensure
- a hospital must be licensed to operate *
- state government oversees with own set of standards
- emphasizes physical plant compliance with:
- building codes
- fire safety
- climate control
- space allocations
- sanitation
76
justice
fairness and equality
77
learning objectives
- perspective on hospital evolution
- factors contributing to hospital growth prior to the 1980s
- reasons for the decline of hospitals and their utilization
- measures pertaining to hospital operations and inpatient utilizsation
- compare utilization measures in US hospitals to other countries
- differentiate among various types of hospitals
- how the ACA affected physician owned specialty hospitals and nonprofit hospitals
- basic concept in hospital governance
- understand licensure, certification, and accreditation and the magnet recognition program
- get a perspective on ethical issues
78
hospital governance
- board of trustees
- chief executive officer
- medical staff
79
which of the following is legally responsible for the operations of the hospital
- CEO -> responsible for day to day operations -> answers the to the board
- chief medical officer
- board of trustees** -> represent the community, business, hospital
80
chief medical officer
-physician
-chief of surgery, chief of radiology -> answers to the chief medical officer
-
81
which level of care would describe a patient receiving a liver transplant
- primary
- secondary -> limited duration, recovery, rehabilitation, common surgery,
- tertiary -> transplant, invasive medical procedure, ICU
