The middlemen for bed demand and supply
With rising demand pressure on Singapore’s hospitals, effective management of the existing supply of beds has been a key focus of public hospitals. Effective bed management affects patient care, manpower, and resource utilisation. Between 2017 and 2022, while Singapore General Hospital (SGH) managed to keep its annual average bed occupancy ratio (BOR) within the government’s guidelines, there were frequent mismatches between the available bed supply and incoming patient demand.
In this case study, Henri Lim, the head of Bed Management Unit (BMU) at SGH explained the challenges facing the team, comparing his unit to an ‘air traffic control tower’ that coordinates the demand and supply of beds in the hospital. “Imagine if you don’t have a coordinator or air traffic control. All the planes that come in, where do they go? Where do they land? At what time? And where should they park?” he said.
What the BOR metric does not show
At SGH, there are close to 1,500 beds across 12 wards, with 70 percent of admissions into the wards coming from the Accident and Emergency (A&E) department and 30 percent from planned procedures. Thus, there is high variability in both numbers and care needs. As the ‘middleman’ who processes the bed admissions, the Bed Management System (BMS) helps the hospital administration and nurses facilitate the admission of patients efficiently, and right-site the patients to the most suitable discipline wards and classes.
SGH's wards are classified into four types with varying levels of government subsidies: Type C (65-80 percent subsidy), Type B2 (50-65 percent subsidy), Type B1 (20 percent subsidy), and Type A (no subsidy). According to the Singapore Ministry of Health guidelines, the BOR should be lower than 85 percent. This would allow hospitals to have sufficient bed capacity to respond to sudden increases in bed demands.
SGH had an annual average BOR of 83 percent between 2021 and 2022. But Lim cautioned that the actual situation was less ideal. For example, Mondays would typically start with 97 percent occupancy (as patients tend not to be discharged over weekends), with only 43 or so empty beds available for up to 250 admission requests in the day.
The BMU team works under intense pressure. Between 2021 and 2022, for instance, SGH had 1,939 beds. More than 10,000 hospital staff dealt with over 72,400 inpatients, over 41,700 inpatient surgeries, over 65,000 day-surgeries, close to 745,000 specialist outpatient clinic attendances and over 109,000 A&E attendances. Total patient days were 527,748, and the average length of stay in days was over seven. More than half of the patient days were in Class C wards, while those in Class A and B1 combined accounted for less than 10 percent.
The BMS uses a system for prioritising bed allocation based on patient condition and other factors like time of the day and available supply of beds immediately or a few hours later. It preferentially allocates patients to the ward of their medical speciality – or to a related discipline if that is not feasible. The quality of the bed allocation depends on the coding of different healthcare resources and actions in the algorithm driving the system. This could become an issue in a dynamic environment, such as during the COVID-19 pandemic, when the rate of patient admissions grew very fast, outpacing the IT team’s response time.
Challenges to managing bed allocations
Another challenge that the BMU team faces is the rigidity in supply in addition to the highly unpredictable nature of incoming demand. Most wards are classified under specific gender, capacity level (single, double, four or six beds), class type and clinical specialisations. Also, discharge times and admission times do not match, so patients have to wait in the A&E department for a bed to become available. Inadequate staff, such as specialist nurses, is another issue. Moreover, while beds may be available, the equipment and infrastructure in the room may not be able to provide the care needed by patients without expensive renovations. This is critical as elderly patients are more likely to suffer from co-morbidities and need more complex care arrangements.
Poor bed management can lead to patients – and staff – experiencing lower satisfaction with their stay. Revenue loss can also arise as SGH would have to upgrade the patient to an empty bed in a premium ward (if available) at the price of a lower-category ward.
Strategies for effective bed management
One strategy for effective bed management is to reduce patients’ stay pre-treatment, such as having same-day admissions for elective patients, whose procedures have been planned in advance.
SGH has also set up an Ambulatory Surgery Centre, a one-stop facility with a comprehensive range of equipment, extending the range of operations that can be performed as elective day surgeries. Thus, no hospitalisation is required of these patients.
Another strategy is intensifying the amount of health services delivered to the patient in the recovery period, so that the patient can be discharged sooner. For instance, physiotherapy is started on the same day after hip and knee replacement surgeries to reduce the patient’s post operative hospital stay to a single day rather than six days.
In recent years, SGH has started forecasting the demand. Each week, the BMU team forecasts the following week’s demand pattern, and if the forecast indicates that the emergency workload has exceeded a certain threshold, it cuts back on the elective admissions for this period. Should unexpected surges still happen, the team meets with nurses to explore options, such as activating ‘surge’ beds in corners of the wards.
Going forward, through data analysis, Lim hoped to highlight gaps in SGH’s current bed management system and improve bed management with a suitable capacity development strategy.
To read more about the bed management system at SGH, please visit the CMP website by clicking here. This case was written by Professor of Operations Management Pascale Crama, Dr Sheetal Mittal and Associate Professor of Operations Management (Education) Marcus Ang at the Singapore Management University.