This dissertation focuses on utilizing data-driven approaches to objectively measure variation in the quality of care across different hospitals, understand how physicians make dynamic admission and routing decisions for patients, and propose potential changes in practice to improve the quality of care and patient flow management. This analysis was performed in the context of Intensive Care Units (ICUs) and the Emergency Department (ED). In the first part, we assess variation in the overall quality of care provided by both urban and rural hospitals under the same integrated healthcare delivery system when augmenting administrative data with detailed patient severity scores from the electronic medical records (EMRs). Using a new template matching methodology for more objective comparison, we found that the use of granular EMR data significantly reduces the variation across hospitals in common patient severity-of-illness levels. Further, we found that hospital rankings on 30-day mortality and estimates of length-of-stay (LOS) are statistically different from rankings based on administrative data. In the second part, we study ICU admission decision-making dynamically throughout a patient’s stay in the general ward/the Transitional Care Unit (TCU). We first used an instrumental variable approach and modern multivariate matching methods to rigorously estimate the potential benefits and costs of transferring patients to the ICU based on a real-time risk score for deterioration. We then used the quantified impact to calibrate a comprehensive simulation model to evaluate system performances under various new ICU transfer policies. We show that proactively transferring the most severe patients to the ICU could reduce mortality rates and LOS without increasing ICU congestion and causing other adverse effects. In the third part, we focus on understanding how physicians make ICU admission decisions for patients in the ED. We first used two sets of reduced-form regressions to understand 1) what and how patient risk factors and system controls impact the admission decision from the ED; and 2) what are the potential benefits of admitting patients from the ED to the ICU. We then proposed a dynamic discrete choice structural model to estimate to what extent physicians account for the inter-temporal externalities when deciding to admit a specific patient to the ICU, to the ward or let him/her wait in the ED. Note that the structural model estimation is still an ongoing process and more investigation is required to fine tune the details. Therefore, we will not discuss the structural model estimation results in this chapter, but only present the modeling framework and key estimation strategy.

Bedside terminals are an approach to data entry that is maximally effective, due to capture at the point of care, to meet the challenges facing nursing today in relation to information documentation. The purpose of this evaluation research study was to determine if bedside terminals are justifiable though a cost-benefit analysis.The General Systems Theory, which was formulated by Ludwig von Bertalanffy in the late 1920's, was the theoretical framework used for this study (Putt, 1978).A non-standardized checklist of factors was developed by the researcher to evaluate the associated costs. related to bedside terminals. The factors included patient census, acuity, lost charges, reimbursement denials, and medication errors.A convenience sample of one surgical nursing unit from a large midwestern metropolitan hospital was chosen for data collection. Based on the literature, monetary values werearbitrarily assigned to the factors. Costs were assigned based on projected figures for bedside terminal implementation in 1993 obtained from the literature. All participants were notified of rights as human subjects and the confidentiality of this study.This study was significant because the results will be added to the limited information on the justification of bedside terminals using a cost-benefit analysis available in the current literature.Projections of bedside terminal costs were limited due to the unwillingness of bedside terminal vendors to provide current costs to compare against the quantitative benefits collected in this study. Reimbursement denials were not obtained due to the accounting practices of the institution. Due to these limitations, a prospective rather than the retrospective approach used in this study for data collection would be recommended to ensure obtaining information on all data elements. The results of this study should be considered when contemplating purchase of bedside terminals. Based on the results of this cost-benefit analysis study, the purchase of bedside terminals is cost-justified. A favorable return on investment of a one year payback was obtained. / School of Nursing

Bedside computer terminals are an approach to data entry that is maximally effective to meet the challenges facing nursing today and process hospital information. The purpose of this evaluation research study was to determine if bedside computers are justifiable through a cost-benefit analysis. Costbenefit analysis was done to determine whether the benefits outweigh the costs involved in implementing a bedside computer system.The General Systems Theory formulated by Ludwig von Betalanaffy was the theoretical framework utilized for this project. A non-standardized checklist of factors was developed from the literature review. The factors included were patient census, acuity, lost charges, reimbursement denials, and medicine errors. Interrater reliability was established by a panel ofthree experts on cost-benefit analysis.A convenience sample of one 42 bed nursing unit from a large metropolitan Midwestern hospital was chosen for data retrieval. One month of financial data was analyzed for this study. The procedures for the protection of human subjects were followed.The study showed that bedside computers are costjustified.-based on the results of the cost-benefit analysis. The projection of cost versus benefits realized from the bedside terminals was limited due to the unwillingness of vendors to share actual cost information. Reimbursement denials were unable to be retrieved because of the financial accounting practices of the institution chosen.A prospective approach rather than the retrospective approach utilized in this study may produce the data necessary for reimbursement denials. Recognizing its limitations, the results of this study should be considered when contemplating the purchase of bedside terminals or the increasingly more advanced technology of hand-held and voice activated computers. / School of Nursing