By Valerie Nelson
December 31, 1997

Quick, a little Health Care 101: How do you measure the size of a hospital? If you answered, "by the number of beds," step to the back of the class. That answer’s years behind the times.

A more accurate measurement includes the services offered and the patients served, experts say. The declining number of beds—and the complicated, unique formula behind calculating how many beds are needed at any one facility—doesn’t fit into a national pattern, according to the American Hospital Association (AHA) in Washington, DC

Even if you’re not a star pupil, you probably don’t need a lesson in the forces revolutionizing health care and making hospitals rethink how many beds are necessary. Rapid consolidation and the growth of managed care have come together to bring about a decline in the number of beds required.

Services, please

"Hospitals now deliver so many different kinds of services that it’s almost hard to tell what a hospital is," said Paul Torrens, MD, professor of health services at the UCLA School of Public Health. It’s no longer a question of beds, but of what services a hospital is trying to deliver, he said.

Thinking about how many beds a hospital needs ties into "the whole nature of the way health care is changing," Torrens said. Healthcare services, once separate entities, now are connected like so many lights on a string. Hospitals are becoming part of integrated delivery systems that are a far cry from the past, when the different facets of health care—prevention, outpatient services, nursing homes, home care—operated independently.

Value for nurses

With the emphasis on measuring hospitals’ shifting from beds to a wider range of services, in some ways hospitals will be a better place for nurses to work, Torrens said. "Nursing used to be identified with just inpatient, bedside care. Now we’re talking about the expertise nurses have. They are more valuable rather than less." In fact, a nursing shortage in the Dallas area is directly attributable to the expanding opportunities for nurses in the hospital setting, said Ron J. Anderson, MD, president and CEO of Parkland Health and Hospital System in Dallas.

From his public hospital perspective, figuring out how many beds are needed is tied to looking at the public safety net infrastructure. "The safety net is full" in Dallas, he said, because one in four Texans is uninsured.

Parkland’s census is measured in "adjusted patient days," which includes outpatient work. Anderson said it’s important to look at different segments of the industry and at particular facilities to determine whether there are too many beds.

One way to make the most of each hospital’s bed count is to link systems, whether they are public or private. "We’re looking at ways we can rationalize services and work cooperatively without building more beds," Anderson said. "It remains to be seen. Can we have hospitals that can do that? Many are afraid the populations [public hospitals] care for are unattractive."

Empty beds vs. ORs

So what should hospitals do when they have low occupancy rates? The controversy is not about the cost of empty beds, but what should be done with the space instead, says Paul Ginsburg, PhD, president of the Center for Studying Health Systems Changing in Washington, DC

"Hospitals’ having a lot of empty beds doesn’t tell you if operating rooms, labs, imaging centers have comparable degrees" of underuse, he said. "More of an issue is having underutilized ancillary facilities."

For example, hospitals with facilities to do open-heart surgery that aren’t used very much are more the problem because of the high cost of equipment and staffing. Extensive literature also shows that outcomes aren’t as good for open-heart procedures done at underused facilities, Ginsburg said.

Hospitals need to consider the overall use of space and determine whether to turn the real estate dedicated to beds into something else, he said.

A public debate

The "very complicated" issue of how many beds to have is evident in the debate over how many inpatient beds to include in the new Los Angeles County-University of Southern California Medical Center, damaged in the 1994 Northridge earthquake, Torrens said.

The hospital, which had 2,000 beds before the earthquake, has been operating with half that ever since. A report by the Healthcare Association of California concluded the facility will need at least 750 beds to handle the demand for emergency and critical care despite the expected surplus of more than 3,100 beds in the area.

The beds issue is a particularly difficult question because that public facility is "the hospital of last resort for the county," Torrens said. "What they are saying is, ‘We need to be able to preserve a certain range of services that these people can’t get anywhere else because they can’t get any insurance. We have to remain large enough and diverse enough to serve their needs.’ "

Public, private

The private and public coming together is "way off still," Torrens said. The healthcare system as a whole needs to develop better ways to insure the poor or pay for their care so that they’ll be more attractive as patients to private institutions, he added.

Communities need to study their demographics to plan the number of beds an institution requires, Anderson said, but beds are just a part of the entire public health infrastructure that needs to be addressed. Managed care has helped address inefficiencies in administration and has decreased bed utilization; the problem remains that patients in the hospital are sicker than they used to be.

Patients in hospitals are more severely ill these days, and "sicker costs more," Anderson said. "You can only use the closing of beds for so long before that won’t start saving you money. We gave up health planning and let the marketplace deal with it. We’re more likely to close public beds through privatization, which are the ones you shouldn’t close."

A look at tomorrow

In the next five to 10 years, the traditional role and structure of the American hospital will be expanded and re-examined, Torrens predicts. New models will spring up that "are much broader and offer a much wider range of services than the old hospital," he said.

The healthcare model developing around the nation is a continuum of services in which the hospital is a large cog in the chain and "there is much more integration of services across lines," Torrens said.

Hospitals in urban areas that are duplicating services "gets to the whole issue of ‘what does the community need?’ " said Carol Schadelbauer, spokesperson for the AHA. Working together is what it will be about. A record number of hospital collaborations and mergers are helping to fuel the downsizing trend, she said.

The shape of each hospital, and the number of beds in it, will evolve slowly over the years as each institution reacts to the needs of the community—healthcare and otherwise—that surrounds it.

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