Stress on the Ward: Evidence of Safety Tipping Points in Hospitals

Abstract

D o hospitals experience safety tipping points as utilization increases, and if so, what are the implications for hospital operations management? We argue that safety tipping points occur when managerial escalation policies are exhausted and workload variability buffers are depleted. Front-line clinical staff is forced to ration resources and, at the same time, becomes more error prone as a result of elevated stress hormone levels. We confirm the existence of safety tipping points for in-hospital mortality using the discharge records of 82,280 patients across six high-mortality-risk conditions from 256 clinical departments of 83 German hospitals. Focusing on survival during the first seven days following admission, we estimate a mortality tipping point at an occupancy level of 92.5%. Among the 17% of patients in our sample who experienced occupancy above the tipping point during the first seven days of their hospital stay, high occupancy accounted for one in seven deaths. The existence of a safety tipping point has important implications for hospital management. First, flexible capacity expansion is more cost-effective for safety improvement than rigid capacity, because it will only be used when occupancy reaches the tipping point. In the context of our sample, flexible staffing saves more than 40% of the cost of a fully staffed capacity expansion, while achieving the same reduction in mortality. Second, reducing the variability of demand by pooling capacity in hospital clusters can greatly increase safety in a hospital system, because it reduces the likelihood that a patient will experience occupancy levels beyond the tipping point. Pooling the capacity of nearby hospitals in our sample reduces the number of deaths due to high occupancy by 34%.

Task Selection and Workload: A Focus on Completing Easy Tasks Hurts Long-Term Performance

“…Second, we show that there are system benefits, in the short-term when workers select these easier tasks as they complete work faster. Third, although prior work suggests that improved performance may eventually hinder performance due to overwork (KC and Terwiesch 2009;Staats and Gino 2012;Kuntz et al 2015) here we show a negative longer-term effect that is consistent with a lack of learning arising from completing easier tasks. Finally, as a part of these models we are the first to show the mechanism through which completion benefits performance -the positive feelings that accrue as work is finished.…”

“…Using multiple settings within healthcare KC and Terwiesch (2009) show that service rates are endogenous to load. Multiple papers have built upon this finding: to replicate it in other contexts (Staats and Gino 2012), to show that quality may suffer due to load (Kuntz, Mennicken and Scholtes 2015), to show that workers may burn out due to load (Green, Savva and Savin 2012) and more generally show how load can alter behavior in an operating system (Tan and Netessine 2014;Berry Jaeker and Tucker 2015;Kim et al 2015). A key assumption in this line of work is that as individuals experience more load, they choose to work faster in the short-term, although this speeding up may negatively impact performance in the long-term.…”

Assessing the Quality of Quality Assessment: The Role of Scheduling

“…Extended periods of excessive workload can cause workers to slow down (Kc and Terwiesch 2009) and can erode service quality (Oliva and Sterman 2001). Heavier workloads can also lead workers to conduct fewer tasks (Oliva and Sterman 2001, Kc and Terwiesch 2012, Kuntz, Mennicken, and Scholtes 2015 and to conduct them less comprehensively, which can manifest as lower service quality (Kuntz, Mennicken, andScholtes 2015, Berry Jaeker andTucker 2016) and as incomplete documentation resulting in lost revenues (Powell, Savin, and Savva 2012). In contrast to workload, we focus on work schedule-in particular, examining how task sequence, tasks scheduled near the end of shift, and prior tasks affect service quality in the form of conducting comprehensive inspections.…”

Redefining clinical leadership for team-course development

“…[22] The complexity of patient care and crowding in the ED and hospital wards are associated with a number of negative health outcomes, including unnecessary deaths, increased waiting times and a decrease in quality of care. [23] These factors necessitate the development of strong interdisciplinary team skills among medical personnel. [24,25] In Norway, inadequate management and leadership affect the day-to-day running of patient services.…”