Centralized Bed Assignment
Maximal bed utilization can only be obtained by centralizing the responsibilities for the placement of patients in hospital beds. Centralized bed assignment is effective only when the hospital operational model has developed a set of priorities surrounding bed utilization and patient placement. These priorities must be followed and understood by all hospital departments.
Bed Assignment Priority
ICU bed availability—Sickest First Operating Room Patients Cath Lab Patients Directs or Transfers
Emergency Department Admissions
Maintaining these priorities allows centralized bed management to make strategic decisions which impact care delivery, optimal bed utilization, and priority placement of patients requiring hospital beds. Use of “Bed Ahead” strategies can be beneficial to maintaining the hospitals ability to serve its patients and use resources in the most efficient manner. Proactive techniques including “Next Week” planning and holding beds in specialty areas of the hospital on Sunday nights can be effective in limiting movement of patients from one unit to another to maintain this priority-based structure.
Hospital Bed Construct
To effectively implement strategies surrounding hospital operational modeling, the hospital bed construct must be designed to consider both the types of patients seen, the service components the hospital has in place, and the growth and vision of hospital management. Hospital bed construct can be divided into the following categories:
Licensed Hospital beds—those beds built and approved for use by patients requiring hospital admission and include ICU beds and med/surg beds Unlicensed hospital beds—include areas in which patients are housed but do not exist on the hospitals unlicensed bed list: Emergency Department, PACU, Cath lab holding, Observation units, and hallway beds.
Although bed type and utilization may be directed by government regulation, the ability to identify the hospital’s needs and develop a bed construct around those needs will significantly impact overall efficiency and flow of patients through the organization. Med/surg beds can be considered under two primary categories:
Specialty beds—Orthopedic, Stroke, Cardiac, etc.
Generic beds—Any patient may utilize the bed
Limitations of the generic bed construct are usually centered around hospital bed numbers and acuity of illness. As hospital services broaden and the acuity of illness increases, specialty utilization becomes a more specific model.
The primary design of bed construct determines needs for acuity, how best to cluster patient types to gain efficiency of care delivery and measure impact on hospital Length of Stay, and other metrics which determine both the quality and operational effectiveness of the organization. An example is Observation Beds—Since this patient type is designated as outpatient, any bed in the hospital can be a recipient of this patient type. This includes Emergency Room beds,
Observation Unit Specific beds and med/surg beds. The impact of this variable bed use has implications surrounding efficiency of patient movement and cost of patient care. Using ED beds for observation uses highly skilled staff to manage lower-level acuity patients and impacts Emergency Bed availability during high census resulting in potential delays in new patient evaluations, increased left without being seen rates, and hospital diversion of EMS.
Use of med/surg beds in a scatter-bed arrangement for observation type patients results in increased LOS, lack of focus on lower acuity patients, and improved bed turns.
Clearly the hospital size, acuity, and occupancy rates would drive hospital construct in a specific direction. Lack of clustering specific patient types (observation and outpatient surgery) regardless of hospital size will not allow the organization to take advantage of the efficient impact this strategy can have on bed utilization and LOS.
Denials management from a system’s perspective links to medical necessity and the development of a system which accurately identifies level of care, upgrades that level from an outpatient to an inpatient status when identified, and can effectively defend the organizations decisions when questioned by either governmental agencies or commercial insurers. Denials fall into three primary areas:
- 1. Medical necessity denials-or level of care—these may also include denials of bed days based on documented patient acuity
- 2. HIM denials—primarily DRG designations which are directed by provider documentation
- 3. Billing denials—these are usually clerical denials in the form of incorrect demographics or other incorrect billing components.
The use of a denials management system for the hospital requires a centralized area for denials which then filter and dispense the denials into those areas which have the proper expertise and team members to effectively manage the denials. The need for Physician oversight cannot be underestimated. Both the medical necessity and HIM denials can clearly be filtered by Utilization management personnel, but physician leadership is mandatory. This construct will allow the most effective focus on denials and can monitor areas requiring operational improvement on the front-end process of medical necessity. With constant monitoring and effective management, the impact on reduction in denials by both governmental agencies and commercial insures will have significant impact on organizational finances and resources required to manage this process.