For years, hospitals have responded to crowded emergency rooms and longer waits for beds by building ever-bigger buildings and spending vast sums - up to $2 million per bed.
But expansion hasn't solved the problem, and the costs are becoming unsustainable. So some hospitals are trying a new tactic: Working more efficiently around the clock.
This month, the New Jersey Hospital Association received a $7 million grant, in part to hire a former Soviet industrial engineer whose forte is smoothing out the flow of hospital patients so they can be treated more efficiently.
Eugene Litvak is a Harvard University professor renowned in hospital circles for employing techniques that carmakers, hotels, and restaurants have used for decades.
If adopted in all New Jersey hospitals, he said, his methods could save at least $300 million and as much as $6 billion annually.
Litvak's challenge is immense. Nationally, 91 percent of hospitals reported ER overcrowding at least one day a week, according to a 2010 survey by the American College of Emergency Physicians.
Overcrowding has worsened in the last year, most hospitals have reported. Nearly one-third said patient boarding - where patients are held in ERs for hours at a time, usually because no beds are available - occurs from five to seven days a week.
According to a report in July from the Philadelphia-based Delaware Valley Healthcare Council, a hospital lobbying group, emergency visits in Southeastern Pennsylvania rose to 1.8 million in 2009, a 32 percent increase from 1998.
The rise of uninsured patients is one factor. Another is that ERs are vanishing. While the number of ER visits has soared from 90 million in 1990 to over 136 million in 2009, more ERs have been closing. One-quarter of America's emergency departments have shut since 1991, including three in the Philadelphia area since 2006.
Alfred Sacchetti, who co-chairs the department of emergency medicine at Our Lady of Lourdes Medical Center in Camden, said that in the 1950s and 1960s, most hospital patients came through the front door. Now he said, most arrive at all hours through the ER, though many executives still run their facilities as Monday-through-Friday-based organizations.
Sacchetti said hospitals can't just build their way out of the crunch. Many other hospital experts agree and are working on solutions.
Lourdes, for example, uses a greeter in the ER to improve patient flow. It also uses nurse-practitioners to write admission orders as soon as doctors order them, speeding admissions and reducing ER boarding.
Thomas Jefferson University Hospital moves patients directly into the emergency department instead of having them wait in a series of queues in the waiting room, said Paris Lovett, deputy medical director. A series of similar strategies has shortened waiting times by half, he said.
The number of patients leaving without being treated is an indicator of how effective an emergency department is, said Henry Unger, chairman of emergency medicine at Holy Redeemer Hospital in Meadowbrook. His the hospital also employs greeters, among other strategies. The percentage of patients who left without treatment fell from 2.1 percent in 2007 to 0.4 percent last year, Unger said.
The ER staffers can't fix the problem by themselves. Litvak traces the root causes of overcrowding to a failure by hospital leaders to manage staffing.
He said the inefficient scheduling of patients for elective care, mostly for surgeries, is often to blame. He discovered something most executives already know: the daily patient census rises and falls like the peaks and valleys of the Himalayas.
Surgeries are among the most profitable procedures in hospitals and offset the costs of care in less lucrative areas. So executives want to please the surgeons, most of whom perform procedures only one or two days a week, often clustering patients on Tuesdays or Wednesdays.
Litvak found that it is often on those days that ERs get overcrowded, because the surgery patients take up so many beds, causing backups and delays downstream.
Litvak's nonprofit Institute for Healthcare Optimization works with hospitals to smooth out scheduling, resulting in more predictable, more efficient, and less costly staffing. He suggests spreading surgeries through the week, and offering separate operating rooms for planned and emergency surgeries.
Helen Darling, president and chief executive officer of the National Business Group on Health, said employers can no longer afford to subsidize unlimited hospital expansion.
The United States already has the most expensive health care system in the world, and "it's killing business and driving jobs out of the country," she said. "Dr. Litvak has been very successful in some great hospitals with his process reengineering."
Scott Hamlin, chief financial and administrative officer for Cincinnati Children's Hospital Medical Center, said Litvak had showed that emergency overcrowding had everything to do with hospital practices.
"He helped us see that our operating rooms, intensive care unit, and emergency department are all connected and that bottlenecks in one area lead to delays throughout the hospital," Hamlin said.
Hamlin said his hospital saved about $100 million in avoided construction costs and raised occupancy from 76 percent to 91 percent. The higher census, along with efficiencies and cuts in surgery overtime, led to higher revenues of $137 million.
Lourdes' Sacchetti said many physicians, including surgeons, understand that hospital medicine today is a 24/7 business.
"The first day of running an operating room on a Saturday won't be a sellout, but when you're innovative, you go through some bumps. Some places will begin performing catheterizations and colonoscopies at night, so their patients don't have to miss a day of work and can go back the next day," he said.
"There are enough CEOs with the foresight to do this. They may lose money for the first couple months, but this is the wave of the future."
Sacchetti said the improvements have a better chance of taking root when a hospital association adopts them.
"An individual hospital CEO is fighting upstream," he said. "But if you have the state's hospital association supporting this, it becomes easier politically for a hospital CEO to get the medical staff on board."
Victor Almeida, associate director of the emergency department of Monmouth Medical Center in Long Branch, N.J., cautioned that Litvak will face barriers from some surgeons reluctant to change their operating schedules.
"I don't want to sit at the table for that meeting, because you'll need a tank and a flak jacket. They will threaten to move their cases to a competing hospital, and that's a threat hospital administrators take seriously," said Almeida.
"But change has to come. If they [surgeons] are not riding this bus, it's going to run them over."
Litvak said his methods do not improve hospital operations on the backs of surgeons, calling cooperating surgeons and their patients the biggest beneficiaries. He said they enjoy more predictable operating hours, fewer bumped surgeries, and greater surgical volume and revenue potential with improved quality of care.
Jesse Pines, director of the Center for Health Care Quality at George Washington University, said some hospitals have tried to implement surgical smoothing, but failed to achieve results, mostly because of poor leadership.
"Making quality improvements requires good leadership," Pines said. "A successful intervention won't work if the hospital is not ready for it."
But he is optimistic. "In the next few years several E.D. [emergency department] measures will become publicly reported," said Pines, formerly with the University of Pennsylvania. "And study after study has confirmed that what's measured gets fixed."
Litvak said he, too, was confident.
"Americans can always be counted on to do the right thing," he chuckled, channeling Winston Churchill, "after they have exhausted all other possibilities."