People do not choose when they become sick, injured or require needed services. Other industries comprehend the nature of their businesses and provide coverage that is appropriate to the defined needs. Within the realm of healthcare, this same type of delivery approach is not evident. Ambulatory services tend to follow “banking” hours. Surgeons schedule their cases based on their conveniences. Hospitals either decrease or increase their staffing for ancillary services based on historical scheduling models rather than a true market defined need. Expensive machinery sits idle at “off” times, decreasing the ability to optimize utilization with a fixed asset.
In numerous studies, recent data have shown that early interventions improve quality and cost metrics. The recently published article in JAMA, “Association Between Wait Times and 30-Day Mortality in Adults Undergoing Hip Fracture Surgery by DPincus and Coauthors,” showed that increasing the wait time for hip surgery increases 30-day mortality. In yet another study, investigators Orosz et al. found delays caused by medical stabilization needs, medical evaluation, operating room and surgeon availability. Ricci et al. found, in a similar patient cohort, that in a subset that underwent cardiac testing prior to surgery, none of that testing led to changes in care. Many payment denials result from patients remaining in the hospital over the weekend waiting for tests or procedures to be done on Monday. ”Medical clearance” on a routine basis without specified indications has not been shown to improve outcomes, causes delays and increases cost. Furthermore, another common reason given for additional testing and consultation, increased malpractice claims, has not borne out to be a valid occurrence.
If we genuinely wish to improve quality and decrease costs, we must not only address what we do but when we do it. Our staffing models will need to adjust to allow for actual 24/7 treatment and coverage, not just filling in the gaps on a “call in” or “emergency” basis. We need to accept the evidence as it is published and adapt our delivery models accordingly. Gone are the days when we fit the delivery of care into our schedules.
Many reasons have been given why this is so difficult. Incentive models are not aligned, coverage issues, overtime pay and lower volume at off hours are just a few examples. None of these reasons are insurmountable if we set our minds to focusing on solutions rather than explaining why we struggle with such problems.
For the betterment of those we serve and the community at large, addressing the extension of our delivery models to fit with the need of our patients, including when they need it, and adoption of outcome-driven research will be required.