Author: Barium iodide
The wind of the waxing moon has been blowing for most of the month, and the temperature has dropped in bursts. It was only five o'clock in the evening, and it was already completely dark.
At the door of the ward, a middle-aged woman was holding a hot water bottle and talking to the doctor opposite.
"We've already turned our ears, nose and throat twice, can we still hang up the bed and go back here, and it's okay to live in the hallway; or we can add money to the ICU..."
"Now that it is out of the ordinary, according to anya (pseudonym), she returns to her hometown to continue treatment, the cost is small, and she lives for a long time."
The woman still wanted to argue, but the doctor patted the woman's arm and murmured softly: Come back.
Why?
This story takes place in the neurosurgery department of our hospital.
"Auntie, it's not that I don't want to take it, we're also pressed by the bed turnover." At that time, the doctor was helpless.
The so-called bed turnover, for clinicians, is a term that cannot be more familiar, referring to the average number of patients admitted to each bed over a period of time.
The calculation method is even simpler and crudeer: "(discharge + number of transfers) / average number of open beds" * 100%
It is not difficult to see that the larger the number, the faster the patient flow, which reflects the higher the efficiency of the department.
In the past 30 years, although the review of top three hospitals has undergone three changes, the indicators related to bed turnover rates have always been among them.
For internal medicine patients and non-surgical patients, the cost of hospitalization in the later stage is mainly based on drug treatment expenses. Therefore, shortening the patient's hospital stay can reduce the proportion of drugs, that is, the proportion of drug costs to total hospitalization costs.
In addition, the faster bed turnover can allow more patients who urgently need medical resources to be admitted to the hospital as soon as possible to maximize the use of medical resources.
If you use data to explain, the total number of admissions to medical and health institutions in China in 2010 was 141.74 million, of which 30.97 million were admitted to tertiary hospitals, while in 2019, the number of admissions to public hospitals was 265.96 million, and the number of admissions to tertiary hospitals was 104.83 million.
Correspondingly, the number of beds in medical and health institutions in China has also shown an increasing trend. In 2010, there were 4.787 million beds in China's medical and health institutions, of which the number of beds in tertiary hospitals totaled 1.065 million, while in 2019, there were 8.806 million beds in China's medical and health institutions, of which the number of beds in tertiary hospitals totaled 2.778 million.
Source: Reference 8
Admissions to tertiary hospitals have more than tripled over the past decade, but the expansion of beds has clearly not kept pace.
The patient's volume increases exponentially, and the number of beds encountered increases slightly. Increasing bed turnover is quite reasonable.
However, reasonable evaluation indicators must be perfect?
The people behind the efficiency
We all know that in all walks of life that are manpower-oriented, behind the efficiency, there are often individuals who accelerate the operation.
Combined with clinical practice, the 15-day hospitalization cycle is not long. Many postoperative complications have a longer window of time.
In the case of anastomosis leaks in colorectal surgery, most of them occur 5 to 7 days after surgery, but some occur two weeks or more after surgery.
A general surgeon at my hospital told me, "The longest I've seen, 20 days, leaked." Now 2 to 3 days after surgery, 4 to 5 days to eat, early discharge. But if it leaks, who is to blame?"
If you are forced to be discharged and go to a lower hospital again to arrange admission, the standard of the referral process has not yet been established, and it is easy to create new problems, "which is very unfriendly to patients."
It is also not "friendly" to clinicians.
The previous patient was not discharged from the hospital, and the new patient was admitted, so the internal medicine medical paperwork could not be finished, and the surgical operation was busy.
Image source: Visual China
"Patients with polyps who cannot be treated in outpatient clinics are received from the digestive endoscopic polyps ward." A friend in the top three gastroenterology department once complained to me: "A patient in three days, from income to discharge, we can't stop at all." It's often the beds that come down, but we're exhausted."
The other extreme is neurosurgery. "Except for the vascular group, nothing else can be turned around." "Doctors want to get patients out of the hospital, but it's not something we can decide."
Failing to meet the assessment KPI, affecting their own salary, the performance of the entire department has been dragged down, so "have to do", and the efficiency pressure and patient problems generated after that are also borne by each person.
It's not just higher-level hospitals that are trapped
Logically, these difficulties are not without solutions.
Most of the lower-level hospitals in China are actually not saturated. As long as the higher-level hospital is willing to "turn down", some problems can be solved.
This is not the case. In recent years, the number of referrals has increased year by year, but the number of downward referrals is much lower than the number of upward referrals.
This phenomenon can also be reflected in the data of the Statistical Bulletin on the Development of China's Health Undertakings. In the decade from 2010 to 2019, the total number of admissions to medical and health institutions in China has less than doubled, while the number of admissions to tertiary hospitals has more than tripled.
In other words, the pressure of bed turnover is still too much on the heads of those "big hospitals".
On the other hand, grassroots hospitals also want to "climb up".
For hospitals, once rated higher, the benefits are self-evident.
The hospital grade can be described as "a comprehensive sign of hospital function, scale, management level, quality level, technical level and service level", and is the "golden signboard" of the hospital's comprehensive competitiveness.
The evaluation of tertiary hospitals also means the increase of charging standards, the tilt of policy resources, and the expansion of disease sources and platforms, which is especially important for county and municipal hospitals.
From the perspective of outpatient costs alone, the registration fee of the early pilot hospitals at all levels had a gap of 15%, and then gradually became 30%. Existing surveys show that in Beijing, for example, the basic registration fee for tertiary hospitals is 40 yuan, that for secondary hospitals is 30 yuan, and for first-level hospitals is 20 yuan.
The gap in hospital registration fees has been visible to the naked eye, and for important resources such as scientific research and teaching that are directly linked to professional titles, the advantages of tertiary hospitals over primary and secondary hospitals can be described as crushing.
Therefore, lower-level hospitals are also squeezed out of the head rating. The indicator of "bed turnover" will also sink, and the problem will also sink.
Trapped in the same assessment indicator, we can't help but look at the top three evaluations.
Breaking the Game: Process Management
At this point, we should perhaps ask: what is the original intention of pursuing bed turnover?
In order to achieve better rankings, rating praise, and win the reputation and sign of the hospital; or, for better and more treatment, convenient for every patient?
Obviously, from the beginning to the present, regardless of whether the action is deformed or not, the purpose is unchanged: medical efficiency.
From this perspective, the optimized space and path become clear.
First of all, the evaluation of bed turnover indicators should not only consider a number, but also combine the specific content of the department, the actual situation of the patient and other factors. Therefore, evaluation indicators should also establish a more diversified and professional evaluation model.
If we look at it horizontally, each country in the world has its own set of hospital evaluation systems. (For specific content related to the top three evaluation system, you can view the previous articles of Lilac Garden: I have changed the canteen to a ward, do you see that the number of beds is worthy of the top three?) ）
In 1917, the United States pioneered the establishment of the JC (Joint Commission) as an independent hospital rating agency. In 1951, the United States and Canada established the Joint Evaluation Committee of American Hospitals to conduct a comprehensive evaluation of various medical institutions.
The British NHS system has developed a star-rated hospital review system, including 21 indicators, which is characterized by the fact that the star rating does not pay attention to the technical level and the size of the hospital, but mainly focuses on the quality of medical services.
Comparison of the 2017 edition of the JCI standard with the 2020 edition of the Tertiary Hospital Evaluation Standard (Source: Lilac Garden Mapping)
The core difference is whether to focus more on results or more on managing the process.
If the selection criteria of the top three hospitals are the "outcome indicators" selection method with the hardware level such as hospital scale and quality as the core, then the JCI evaluation index is set for the establishment of the hospital's "patient safety and quality improvement" system, which is a "process management indicator".
Gu Xin, a professor at the School of Government and Management of Peking University, has publicly pointed out in the People's Network that China's hospital rating is closer to an administrative act and is not entirely evaluated according to objective factors such as the quality of hospital services. He suggested that hospital ratings "are not management behaviors, but a service behavior, and third-party certification bodies should be introduced" and that "the introduction of competition and mutual promotion in the certification process is a fundamental way to improve China's hospital rating system".
In addition, a noteworthy idea is the rational implementation of "two-way referral".
In fact, if we start from the perspective of "people-oriented" and better implement the "downward referral" in the two-way referral system, we can also reduce the pressure on the beds in the higher-level hospitals, alleviate the expenses of patients, and achieve a win-win situation.
After all, in the medical environment, what we need to solve is not "how big and fast the hospital is doing", but "what are the key points that need to be paid attention to in the process of hospital doing well", and finally serve the diagnosis and treatment of patients.
Curated by: Carollero
Executive Producer: Gyouza
Title image source: Visual China
Resources:
1. Shao Zhu. Factors that increase bed turnover. Hospital Management in China. 1990(01):12.
2. Bed occupancy rate and bed turnover rate of hospitals at and above the county level in the health department in 1981. Health Economy. 1982(02):95.
3. "General Hospital Graded Management Standards (Trial Draft)" Wei Yi Zi (89) No. 25. Health Economy.
4. Evaluation Criteria for Tertiary Hospitals of the National Health Commission (2020 Edition).
5. Yi Zhiyong, Huang Shouhe. The effect of hospital bed turnover rate on the proportion of drugs. Chinese Pharmacist. 2016; 19(02):316-8.
6. Ren Guohong, Yin Xingyan. A study on the number of bed turnover as a factor stimulating the economic growth of hospitals. Armed Police Medicine. 2002(11):675-6.
7. Statistical Bulletin of The Development of China's Health Undertakings in 2010.
8. Statistical Bulletin on the Development of China's Health and Health Undertakings in 2019.
9. Statistical Bulletin on the Development of Health Undertakings in China in 2011.
10. Hyman N, Manchester TL, Osler T, Burns B, Cataldo PA. Anastomotic leaks after intestinal anastomosis: it's later than you think. Ann Surg. 2007;245(2):254-8.
11. Shen Ying, Huang Weiran, Ji Shuyu, Yu Jia, Li Mujun. Systematic review of the status quo, effect and problems of two-way referral in China from 1997 to 2017. Chinese General Practice. 2018; 21(29):3604-10.