FULL TITLE

Management of hospital bed allocation

keywords

ethnography, responsibility, problems

Problem Description
Bed Management was a key theme apparent throughout our ethnography at three hospitals in the North of England over a two-year period. Indeed the hospital system – staff, information systems, medical and surgical equipment and so on – can be seen as a bed management system in terms of the process of treating patients in a timely, safe and effective manner. If the allocation of beds is not effectively managed then the hospital system is no longer dependable.

Bed management is an abiding concern, common throughout the National Health Service (NHS). Thus there are generic issues that can be explicated through the use of ethnographic study. For example, bed management can be seen as the broad ‘problem’, but contained within it are more specific issues e.g. ‘winter planning’, when the hospitals try to plan for ‘known’ seasonal problems. Bed Management in the NHS Trust here is the responsibility of the Bed Manager, but is inherent in the work of ward staff, clinical managers, directorate managers, appointments staff, waiting list staff and so on. Problems can arise with the bed management systems for a range of reasons which are outlined here and detailed in the example below: accident and emergency admissions which cannot be foreseen; delays in discharge of patients, e.g. due to lack of occupational therapist assessment of home environment, leading to ‘bed-blocking’, lack of up to date data on the Management Information System.

Example
The example detailed here highlights the need to document the responsibilities associated with a system and also to show how work gets done in a real-time real-world situation. The availability of hospital beds across the two sites is co-ordinated by the Bed Manager (BM).

The ‘bed availability’ data as available on the Management Information System (MIS) may be seen as a ‘bad’ record for a number of reasons to do with the lack of a standardised approach to information collection, time lag between information collection and its appearance in the MIS database. The role of the BM is to constantly monitor and maintain the process of bed management in such a way as to avoid a situation where no beds are available. At a more local level, the directorate managers and ward managers monitor bed management.

Early one morning at the hospital during fieldwork with the Directorate Manager of Orthopaedics (DMO). The DMO got the latest report from the Management Information System regarding the current state of play for admissions. This report indicated that, should all planned admissions proceed across the Trust, then the Trust would be “minus nine beds” i.e. there would be a shortfall of nine beds between planned and actual admissions for that day. It was generally agreed at the time that this was due to a road traffic accident causing unforeseen admissions. The DMO stated that she had a set of “the usual rituals” which she carried out in this type of situation, particularly given that the MIS dta may not be up to date.

The ‘usual rituals’ involved going to the wards of her directorate in order to ascertain an accurate account of the beds situation for the orthopaedics directorate. The physical visit to the ward was deemed necessary as we had been told that “ward sisters sometimes lie” about the availability of beds on their wards. Even so, the beds display board on the ward could not give a entirely accurate picture of the situation as it was not possible to represent all circumstances on it e.g. a bed may be shown as occupied but the patient may be discharged that day following a visit from a consultant, physiotherapist and so on.

It was therefore necessary to speak to a number of staff with local knowledge of the situation for different patients in order for the DMO to establish that her directorate was not under pressure in terms of bed availability for that day. It is worth noting here that the DMO establishes an acceptable situation for her directorate only and is not involved in alleviating problems in other directorates. What is also shown here is that explicating this work is not simply a question of medical staff seeing what is 'in the bed management figures' and then automatically working out what should be done. 'What is in the figures' is itself something that has to be worked out, and working it out involves balancing operational and organisational objectives and priorities. The bed management figures and the beds board are the end product of a series of procedures. These procedures make up the bed management system and are designed to give a picture, a representation, of the 'bed position’ embedded in a nest of interactional, organisational and operational contingencies.

Papers

Karen Clarke, John Hughes, Mark Rouncefield and Terry Hemmings. (2003) "When a bed is not a bed: The situated display of knowledge on a hospital ward" in O'Hara, K., Perry, M., Churchill, E. and Russell, D. (Eds) (2003) Public and Situated Displays. Social and interactional aspects of shared display technologies. Kluwer (2003)

Clarke, K., Hartswood, M., Procter, R. And Rouncefield, M. (2003) 'Trusting The Record. Methods of Information in Medicine, 2003. 42: pp 345-352.

Clarke, K., Hartswood, M., Procter, R., Rouncefield, M. And Slack, R. “Minus nine beds”: Some Practical Problems of Integrating and Interpreting Information Technology in a Hospital Trust. In Bryant, J. (Ed.) Proceedings of the BCS Conference on Healthcare Computing, Harrogate, March 18th-20th, 2002. pp219-225

Clarke, K., Hartswood, M., Procter, R., Rouncefield, M., Slack, R. And Williams, R.(2002) "Improving ‘Knife to Skin Time’: Process Modelling and New Technology in Medical Work". Health Informatics Journal, 8(1). Sheffield Academic Press, p. 41-44, 2002.

Clarke, K, Hartswood, M., Procter, R., And Rouncefield, M (2001). Hospital Managers Closely Observed: Some Features of New Technology and Everyday Managerial Work. Journal of New Technology in the Human Services, vol. 14 (1/2), p. 48-57, 2001.