Boundaries of Focus and Volume: An Empirical Study in Neonatal Intensive Care

Abstract

Our study contributes to the scholarly debate whether organizational units should have a narrow focus and admit a homogeneous patient cluster or whether they should admit a pool of patient clusters. We investigate whether the benefits of increased volume through pooling patients outweigh the disadvantages of increased heterogeneity and pursue our analysis in the context of neonatal care. Our empirical studies relies on 4020 patient episodes collected in 18 German neonatal intensive care units and we distinguish between two patient clusters that differ with respect to the inherent medical risk and operational heterogeneity. Cluster 1 consists of very‐low birth weight (VLBW) infants with increased risk of complications but similar service trajectories and lower operational heterogeneity. Cluster 2 contains non‐VLBW infants with lower risk of complications but more diversity in disease patterns and higher operational heterogeneity. Our analysis shows that cluster volume, that is, the unit's absolute patient volume in a cluster, is positively related to process outcomes as indicated by decreasing length of stay. This relationship is found for both clusters. Regarding focus, we do not find any evidence of positive effects. In fact, we even find that cluster focus, that is, the unit's relative volume of the cluster, is detrimentally related to process outcomes for non‐VLBW patients with lower risk of complications and more operational heterogeneity. This indicates that organizational units providing services for complex patients should not have a narrow focus, but should rather provide services for related patient clusters in order to achieve higher volume levels within the unit.

Does Focus Improve Performance in Elective Surgery? A Study of Obesity Surgery in Sweden

“…Our results are not consistent with the recent study by Miedaner and Sülz [18], which found negative effects from focus in neonatal intensive care. A possible explanation of the incongruent results would be that patient characteristics moderate the impact of focus on performance.…”

“…It would be unreasonable to assume that obesity surgery is on the extreme routine end of this scale, given that many obese patients have comorbidities that increase unpredictability and that many simpler elective procedures exist. However, we argue that the current standardized nature of the obesity surgery procedures means that patients undergoing obesity surgery can be characterized as relatively routine elective patients, and that this is a likely explanation of our results in relation to the results of Miedaner and Sülz [18].…”

“…The authors call for more research to verify their findings in the context of specific conditions, using condition-specific quality metrics, to be able to give more specific advice to hospital managers who wish to implement such reorganizations. For complex patients, this has been addressed by Miedaner and Sülz [ 18 ] in a study of neonatal intensive care units, which confirmed that focus has no effect, or a negative effect, on length of stay in this context. The effect of focus has been extensively evaluated in the context of cardiac care, e.g., [ 4 , 5 , 6 , 19 ], but there are few studies in the context of other conditions, especially at the routine end of the complexity spectrum.…”

“…Hospital focus and department focus constituted the two explanatory variables. In line with previous studies [ 4 , 5 , 6 , 18 ], we conceptualize focus as an emphasis on a particular service segment (i.e., obesity surgery) and operationalize it as the number of obesity surgery patients in relation to the total number of patients. The annual number of obesity surgery admissions divided by the annual number of total admissions to the hospital was used as our measure of hospital focus .…”

“…For instance, research has indicated that focused health units are unsuitable for obstetric care due to the difficulty of separating "simple" conditions from complex conditions in the context of pregnancy [27]. As mentioned above, there has similarly been no positive effect from focus identified in the complex setting of neonatal intensive care [18].…”