Artificial Variability Research Picks Up Momentum
Boston Area Studies Results Encouraging

Excerpt from: "New Methodology Promises to Help ICUs" American
Health Consultants Critical Care Alert, Volume 9 Number 3, pp.33-35.

Artificial variability research from Eugene Litvak, PhD, professor of health care and operations management, and his colleagues at the Boston University School of Management has made considerable progress since we first reported it in June 2001.

Litvak and fellow researcher Michael E. Long, MD, adjunct associate professor of health care and operations management at Boston University, recently completed a study funded by the Massachusetts Department of Public Health to find root causes and test hypotheses for emergency room diversion at two large hospitals in the northeast.

The pair tested three primary hypotheses for ED diversion: Patient overuse and an increase in patient ER flow; internal problems in the emergency room such as slow processing, too few cubicles, etc.; and back-up because patients can’t get into ICU or floor units.

Litvak and Long found that only the last of these correlated highly with times most surgical patients left operating rooms and post-operative care units floor beds, which effectively turned ED patients who would otherwise have been moved into ICUs or on to floors into “boarders” who blocked the patient flow. Litvak says that findings support his thesis that emergency department performance itself almost doesn’t play any role in ED patient diversion.

Long notes that he and Litvak have also been looking at other effects of this kind of variability in surgical caseloads throughout the hospital. “One study showed patients receive better care in ICUs, so there’s a quality of care issue here, too,” Long says. “Because we can’t staff to the peaks anymore, we know that on some days everyone is going to be overworked, which is when many medical errors occur.”

He adds that artificial variability adversely affects nursing morale and retention, thus exacerbating an already problematical nationwide shortage of nurses as it forces nurses to work overtime.

Smoothing Surgical Admissions
Once the patient flow problem is identified as lack of internal beds, Litvak says, the question becomes why there are enough beds at some times but not at others. Two forces compete for beds, Litvak says: the emergency department and the operating rooms. While hospitals can’t control the number of ED patients, altering scheduled surgeries can smooth operating room flow and relieve pressure on the ED and ICU. By smoothing the scheduled surgical admissions hospitals can see what additional resources are needed, Litvak says, and only the uncontrollable unscheduled demand remains, which makes justifying funding for additional beds a much easier task.

Two facilities Litvak and Long hope to study next are Boston Medical Center and Holy Family Hospital in Methuen, MA. John B. Chessare, MD, pediatrician and chief medical officer at Boston Medical, says his facility has signed on to study its artificial variability and is committed to making changes the study suggests.

Chessare, a devotee of system dynamics, says that very few hospitals are managed scientifically. “ED diversion is an example of a supply big enough to handle the demand but inefficiently used,” Chessare notes. “Dr. Litvak’s tool is routinely used in every other industry and I think the take-home message here is that the dichotomy between physician and non-physician leaders is very silly.”