As demand for healthcare increases, hospital managers are faced with the prevalent challenge associated with patient flow and capacity management. Patient flow is the movement of patients through a healthcare facility (Hall 2013). The aim of this dissertation is to investigate how the behavior and decisions of workers and hospital managers improve these issues. Specifically, I am interested in understanding 1) hospitals' response to boarding crises, and 2) organizational approaches to improve patient flow.
In Chapter 1, we examine the impact of two responses, urgent response [code yellow (CY)]: a Massachusetts mandated policy to reduce boarding crises whenever patients in the ED experience long wait times, and prevention response [pre-discharge orders (PDO)]: a health IT coordination tool to facilitate patient discharge, on patient length of stay. Using three years of inpatient level data, we find that patients with a PDO have a shorter length of stay (LOS) compared to patients without a PDO after accounting for endogeneity using an instrumental variable (IV). Conversely, using a survival analysis approach, we find there is no significant impact on LOS for patients who experience a CY during their hospital stay versus patients who do not. We also find the urgent response crowds out the prevention response. The likelihood of physicians using PDOs decreases when hospital managers call a CY. Furthermore, we find that PDO results in more discharges in a day compared to CY and that the use of PDOs often reduces the need to trigger a CY. Thus, we find that the state-mandated urgent response creates a state of chaos that deters physicians from investing in actions that could prevent future boarding crises. The study provides empirical evidence that demonstrates pressure to produce results today impedes workers’ efforts to improve future performance.
In Chapter 2, we investigate the impact of external collaborative coordination in improving the efficiency of a dedicated observation unit (DOU). The DOU is a unit in the hospital designed to treat observation patients. In July 2018, the unit expanded to treat patients with higher medical complexity which increased the demand and variability in the unit. Using difference-in-difference with inverse probability weights and instrumental variables (IV) approach we examine the operational cost and the efficiency gain respectively, of this expansion. We find that the observation LOS increases in the unit after the unit expanded. However, using an IV approach, the DOU gains efficiency that results in a reduction in LOS for the observation patients cared for in the unit compared to observation patients cared for off-service in the inpatient unit. We find that our results are driven by external collaborative coordination, which enables coordination amongst the cross-functional team as well as external collaborators.
In Chapter 3, we study the impact of dedicated capacity on overall hospital performance. In this essay, we study the potential benefit of pulling short-stay patients out of the inpatient unit to be cared for in the DOU thus freeing up beds for vulnerable patients. Using a difference-in-difference approach with propensity score matching, we find that boarding time decreases for vulnerable patients as a result of bed availability in the inpatient unit. However, LOS in the inpatient unit increases. Furthermore, we find no impact on 30-day readmission. We attribute the increase in LOS to the higher volume of vulnerable patients who are now able to receive care in the inpatient unit.
Together, these studies extend current knowledge and provide new insights to current studies addressing the movement of patients through a healthcare facility particularly when there is supply and demand mismatch. Through this dissertation, contribution is made to literature on patient flow, capacity management and coordination. Furthermore, it offers practical implications for hospital managers by demonstrating that complex operational problems can be minimized by reducing information gap through coordination.
| Identifer | oai:union.ndltd.org:bu.edu/oai:open.bu.edu:2144/42998 |
| Date | 10 September 2021 |
| Creators | Adepoju, Temidayo Amaju |
| Contributors | Tucker, Anita L. |
| Source Sets | Boston University |
| Language | en_US |
| Detected Language | English |
| Type | Thesis/Dissertation |
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