Obstetrics, however, provides just one example of the many facets of inherent variation among different service lines. For example, inpatient pediatric census tends to be highest in the winter due to higher rates of infectious disease, respiratory infections and gastrointestinal disorders. Emergency department (ED) volumes fluctuate substantially by season, day of the week and time of day. Elective and preventive services volumes have declined over the past couple of years due to the economy and the potential to postpone or forgo care such as mammography screenings and well-woman gynecologic exams.
Implications of Inherent Variation
Fluctuating levels of clinical activity are a reality across all service lines, influencing discrete decisions about staffing the next shift, as well as strategic decisions about capital expenditures. Random fluctuations can be problematic, diminishing the capacity to address problems proactively. When clinical activity ebbs, valuable resources, including staff, beds and the operating room (OR) are underutilized. When the pendulum swings, insufficient capacity creates operational bottlenecks, potentially resulting in lost revenue.
Census variability also creates clinical problems, potentially leading to compromised patient safety and increased liability. When a clinical unit is stretched to its limits, providers may fail to recognize a crisis and mount the most effective response. Census levels are lower at off hours, but available data suggest that clinical outcomes suffer at these times, perhaps because there is insufficient expertise immediately available to best manage emergencies.
Determining “Controllable” Fluctuations
Variations in organizational census and case mix may appear largely random, but health care leaders can, in fact, exert a surprising degree of influence over the ebb and flow of patient care. Most obviously, organizational structures and physician practice patterns influence where and how patients receive care. The census in the ED, labor and delivery and the OR all reflect decisions about scheduling procedures and the availability of office hours for urgent care during evenings and weekends.