This paper responds to a call for a focus on care pathways when designing and constructing health-care facilities. Traditionally, hospitals were designed around specialties and departments rather than around the needs of patients. Patients often spend most of their time in hospitals waiting for something to happen, with large areas provided for this inactivity.
The situation is often exacerbated by the inefficient management of admission and discharge. A consequence is that in many hospitals the flow of patients is inefficient, dislocated and disorganized. Considerations of both quality and efficiency point to the need to systematize processes where possible. Although patient pathways have been defined in various ways, 22 and there is debate over the scope of what is included in a pathway, they seek to describe optimal packages for particular syndromes and, ideally, encapsulate measurable inputs and outcomes.
In this context, it is important to recognize that processes do not stop at the hospital door. Care is not an isolated event, but usually a short episode in a longer patient journey. Integrated pathways that are developed by multidisciplinary teams and plan for pre- and post-hospital care can inform strategies that avoid unnecessary hospitalizations.
Care pathways seem to provide a basis for using health-care demand, derived from demographic and epidemiological data, to plan capital investment in the health sector. Interestingly, these are hospitals operating in competitive market environments, and are thus forced to pay more attention to long-term sustainability and performance, even if this means higher initial capital costs.
While they largely focus on re-engineering of internal processes, they also involve different understandings of capacity that are relevant to hospital planning. The concept of lean thinking is most commonly associated with Japanese manufacturing and was pioneered by Toyota Motor Corporation in the s. Several lessons from lean thinking are relevant to health care.
One cause of bottlenecks in hospitals is semi-autonomous departments seeking to optimize their own functioning without considering how this affects the performance of others. Anything that eases throughput by releasing the bottleneck potentially adds value to the system. However, improving the efficiency of only one part of the system may not improve overall efficiency.
Reducing crowding in emergency departments, for example, requires strategies that go far beyond the department. Can these insights from industrial environments really be translated into hospital capacity planning and design? While lean thinking is not a new concept, until recently it has only been applied to health care to a limited extent.
Patients are processed in batches before being moved on, often to wait in a queue for the next stage. This results in long lead times for processing and high costs in terms of space and capacity, and for patients in terms of their time. In health care, waste — in terms of time, money, supplies and goodwill — is a common problem.
Lean thinking sees the value as defined in terms of the primary customer, the patient. There are several ways of achieving this, each with implications for the design of the supply chain. All require predictability and the consistent interchangeability of processes. A major implication of applying management theory to health care is the need to separate different flows of patients, work and goods, enabling each to move according to its own logic and pace.
For hospitals, this means that the focus should not be on similar clinical conditions but rather on similar processes. The new system led to significant improvements in several key performance indicators, including mean waiting and treatment time. A key to improving patient flow is the smoothing of peaks and troughs in workload. Thus, advances in medical imaging increasingly allow decentralization, which can facilitate high-velocity flow.
A failure to distinguish between the two can lead to the view that queuing is due simply to a lack of capacity in terms of beds, facilities, diagnostics, nurses or doctors.
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The elevators are more likely to cause queues in a surge situation, such as when the stores need to be evacuated, whereas escalators are more forgiving in such circumstances. As these examples show, while insufficient supply may well be a problem, it can only be understood as a function of the way that the service is configured.
Improving patient flow has major implications for our understanding of hospital capacity. Rather than counting beds, a new definition of capacity could start from a description of the pathways travelled by patients, whether in batches or as flows, followed by identification of those elements that can constrain them the bottlenecks. In some cases, this could be the number of beds but in others it will be operating theatres, diagnostic equipment or particular specialist staff — in each case, these depend on the particular site and its relation to the local health-care economy.
It is necessary to examine how these elements are configured within and outside hospitals, recognizing that many pathways will join together at bottlenecks, such as in operating theatres, before going their separate ways. The key to successful capacity planning is then to ensure that each patient travels along the shortest or least costly path possible within the network, encountering as few delays at bottlenecks as possible. This approach has major implications for hospital planning.
By differentiating those processes that are best undertaken in batches and those that should be continuous flows, it is possible to develop appropriate simulation models that integrate the demands on the hospital and the capacity to meet them. Many of the challenges we have described will be familiar to hospital physicians, managers and planners, who will recognize the application of management principles in health care even if they are not always identified as such.
Furthermore, these principles are mainly concerned with optimizing processes and not with capacity planning. Why are hospitals still predominantly planned on the basis of bed numbers? Several factors are at play. Hospital planners may be well aware of the limits of using beds as a measure for future capacity, but may use it as a shorthand for the physical space in terms of square metres needed by different departments. Furthermore, as mentioned previously, most systems of capacity planning still focus on hospitals and do not include primary health care or social care.
As care pathways are likely to have the biggest impact when applied across settings of care, they assume particular importance in integrated systems of planning. In addition, the development of care pathways across health systems is only beginning in many countries and, usually concerned with chronic diseases, they do not yet cover a sufficient number of medical conditions. The way capital has been financed historically is also important. New facilities were financed from elsewhere, such as government funds, with no incremental risk to health-care providers. We believe that it may not be a coincidence that those hospitals in our sample with the greatest exposure to risk have used care pathways to plan hospitals.
This does not mean we advocate that hospitals should be run by commercial firms, but rather that hospital planning needs to ensure the long-term viability of new or refurbished facilities; in a sense, the match between the clinical and financial functioning of the hospital. The increasing use of public-private partnerships for managing hospitals, including in developing countries, may provide a powerful incentive for better hospital planning and performance, 43 but only if they avoid the pitfalls of some existing schemes.
Care pathways seem to be a promising way of conceptualizing hospital capacity in planning exercises, but they are a methodology that needs to be developed further. Challenges include the systematization of care pathways, their large number and propensity to change, the integration of health-care demand and supply, and the linking of resources to care pathways. However, we caution against overly rigid interpretation and implementation of these concepts in health care.
The focus is often efficiency - oriented, relies heavily on certainty to ensure cost minimization and seeks to engineer stability into the system to avoid costs resulting from disturbances occurring in the supply chain. Lean principles should not be over-zealously applied at the expense of responsiveness — indeed, building in modest spare capacity can have disproportionate benefits on the effectiveness of the delivery process.
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Finally, although systems thinking can help explain the wider inter-relationships between health-care processes, care needs to be taken at each level in the system when considering problems or solutions. For example, when planning to improve the flexibility and adaptability of a local health-care economy, should this be targeted at the level of the ward, department, hospital or local health system as a whole? Although health care is increasingly being shifted away from expensive hospital facilities, the demand for new hospitals remains high across the world.
Finding better ways of planning and operating hospital capacity is essential for delivering sufficient capacity at the right price to meet future health-care needs. The paper forms part of a wider study of health capital investment in Europe that has been undertaken by the European Observatory on Health Systems and Policies and the European Health Property Network.
Bull World Health Organ. PMID: Find articles by Bernd Rechel. Find articles by Stephen Wright. Find articles by James Barlow.
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Find articles by Martin McKee. Corresponding author. Correspondence to Bernd Rechel e-mail: ku. All rights reserved. This article has been cited by other articles in PMC.
Need for innovation Traditionally, hospitals were designed around specialties and departments rather than around the needs of patients. Care pathways Considerations of both quality and efficiency point to the need to systematize processes where possible.
Applying these principles Can these insights from industrial environments really be translated into hospital capacity planning and design? Improving patient flow A major implication of applying management theory to health care is the need to separate different flows of patients, work and goods, enabling each to move according to its own logic and pace.
Specialty in Europe
A new understanding of capacity Improving patient flow has major implications for our understanding of hospital capacity. Discussion Many of the challenges we have described will be familiar to hospital physicians, managers and planners, who will recognize the application of management principles in health care even if they are not always identified as such.
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Funding: The paper forms part of a wider study of health capital investment in Europe that has been undertaken by the European Observatory on Health Systems and Policies and the European Health Property Network. Competing interests: None declared. References 1.
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Financing and planning of public hospitals in the European Union. Health Policy. Capacity planning in health care: a review of the international experience.
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