Using simulation modelling to transform hospital planning and management to address health inequalities.

Health inequalities are a perennial concern for policymakers and in service delivery to ensure fair and equitable access and outcomes. As health inequalities are socially influenced by employment, income, and education, this impacts healthcare services among socio-economically disadvantaged groups, making it a pertinent area for investigation in seeking to promote equitable access. Researchers widely acknowledge that health equity is a multi-faceted problem requiring approaches to understand the complexity and interconnections in hospital planning as a precursor to healthcare delivery. Operations research offers the potential to develop analytical models and frameworks to aid in complex decision-making that has both a strategic and operational function in problem-solving. This paper develops a simulation-based modelling framework (SimulEQUITY) to model the complexities in addressing health inequalities at a hospital level. The model encompasses an entire hospital operation (including inpatient, outpatient, and emergency department services) using the discrete-event simulation method to simulate the behaviour and performance of real-world systems, processes, or organisations. The paper makes a sustained contribution to knowledge by challenging the existing population-level planning approaches in healthcare that often overlook individual patient needs, especially within disadvantaged groups. By holistically modelling an entire hospital, socio-economic variations in patients' pathways are developed by incorporating individual patient attributes and variables. This innovative framework facilitates the exploration of diverse scenarios, from processes to resources and environmental factors, enabling key decision-makers to evaluate what intervention strategies to adopt as well as the likely scenarios for future patterns of healthcare inequality. The paper outlines the decision-support toolkit developed and the practical application of the SimulEQUITY model through to implementation within a hospital in the UK. This moves hospital management and strategic planning to a more dynamic position where a software-based approach, incorporating complexity, is implicit in the modelling rather than simplification and generalisation arising from the use of population-based models.

Desempenho dos hospitais mineiros no PNASS 2015- 2016: uma análise a partir de clusters de desempenho e perfis de atendimento / Performance of Minas Gerais hospitals in PNASS 2015-2016: an analysis based on clusters and service profiles

Os hospitais têm passado por grandes transformações, que envolvem mudanças no seu papel, para além da dimensão técnico-científica. Ao longo de décadas, a Atenção Hospitalar tem sido um dos principais focos de discussão acerca da assistência no Sistema Único de Saúde (SUS) e, na busca de novas perspectivas para o cenário hospitalar brasileiro, algumas estratégias são apontadas como forma de se induzir maior eficiência sistêmica: entre elas as avaliações em saúde, que propiciam diagnósticos vitais relacionados à qualidade dos serviços. Nesse âmbito, a presente pesquisa teve por objetivo relacionar o desempenho dos hospitais de Minas Gerais, que participaram do Programa Nacional de Avaliação de Serviços de Saúde ­ PNASS 2015/2016, com as variáveis porte, macrorregião, gestão e esfera administrativa e, sobretudo, explorando as características relacionadas à sua produção hospitalar e ambulatorial, bem como sua participação no contexto das Redes de Atenção à Saúde (RAS). Além disso, buscou-se apresentar através de mapas de pontos a localização das instituições avaliadas, a fim de demostrar o padrão de distribuição dos hospitais dentro das macrorregiões mineiras. Em relação à metodologia empregada, trata-se de um estudo descritivo transversal, quantitativo, com a utilização de dados secundários, obtidos dos bancos de dados do PNASS 2015/2016, SIH e SIA, que envolve ainda dados secundários oriundos de deliberações da Secretaria de Saúde do Estado de Minas Gerais. A análise estatística foi realizada por meio do Software RStudio 4.1.0, em associação com o Microsoft Excel 2018, e para o georreferenciamento utilizou-se o software QGIS. Os achados apontaram uma associação entre as variáveis testadas e o desempenho e, em especial, observou-se uma relação entre a participação nas RAS com melhores resultados, sobretudo nos hospitais participantes das redes temáticas de Urgência e Emergência e de Saúde Materno-infantil. Na perspectiva das produções hospitalares (AIH aprovadas) e ambulatoriais (procedimentos da tabela unificada), identificou-se uma relação semelhante, sendo notável que os hospitais de desempenho ótimo apresentam produção mais volumosa e voltada para agravos de alto impacto na saúde pública. Assim, destaca-se a importância das avaliações em saúde e a necessidade de promoção da cultura avaliativa na atenção terciária e, nesse cenário, ressalta-se a contribuição do PNASS como estratégia pública de avaliação e a importância de se analisar com profundidade a influência dos perfis institucionais no desempenho.

The Hospitals have undergone major transformations, which involve changes in their role, beyond the technical-scientific dimension. For decades, Hospital Care has been one of the main points of discussion about assistance in the Unified Health System and, in the search for new perspectives for the Brazilian hospital scenario, some strategies are pointed out as a way to induce greater systemic efficiency: including health assessments, which provide vital diagnoses related to the quality of services. In this context, this research aimed to relate the performance of hospitals in Minas Gerais, which participated in the National Program for the Evaluation of Health Services - PNASS 2015/2016, with the variables size, macro-region, management and administrative sphere and, above all, exploring the characteristics related to its hospital and outpatient production, as well as its participation in the context of the Health Care Networks. In addition, an attempt was made to present the location of the evaluated institutions using dot maps, in order to demonstrate the distribution pattern of hospitals within the macro regions of Minas Gerais. Regarding the methodology used, this is a descriptive, cross-sectional, quantitative study, using secondary data obtained from the PNASS 2015/2016, SIH and SIA databases, which also involves secondary data from deliberations by the Secretariat of Health of the State of Minas Gerais. Statistical analysis was performed using the RStudio 4.1.0 Software, in association with Microsoft Excel 2018, and for georeferencing, the QGIS software was used. The findings pointed to an association between the tested variables and performance and, in particular, there was a relationship between participation in the Health Care Networks with better results, especially in hospitals participating in the thematic networks of Urgency and Emergency and Maternal and Child Health. From the perspective of hospital (approved AIH) and outpatient (procedures in the unified table) production, a similar relationship was identified. Thus, the importance of health assessments and the need to promote an evaluative culture in tertiary care are highlighted and, in this scenario, the contribution of the PNASS as a public evaluation strategy and the importance of analyzing in depth the influence of the institutional profiles on performance.

Impact of nationwide centralization of oesophageal, gastric, and pancreatic surgery on travel distance and experienced burden in the Netherlands.

BACKGROUND: This study aims to assess the impact of nationwide centralization of surgery on travel distance and travel burden among patients with oesophageal, gastric, and pancreatic cancer according to age in the Netherlands. As centralization of care increases to improve postoperative outcomes, travel distance and experienced burden might increase. MATERIALS AND METHODS: All patients who underwent surgery between 2006 and 2017 for oesophageal, gastric and pancreatic cancer in the Netherlands were included. Travel distance between patient's home address and hospital of surgery in kilometres was calculated. Questionnaires were used to assess experienced travel burden in a subpopulation (n = 239). Multivariable ordinal logistic regression models were constructed to identify predictors for longer travel distance. RESULTS: Over 23,838 patients were included, in whom median travel distance for surgical care increased for oesophageal cancer (n = 9217) from 18 to 28 km, for gastric cancer (n = 6743) from 9 to 26 km, and for pancreatic cancer (n = 7878) from 18 to 25 km (all p < 0.0001). Multivariable analyses showed an increase in travel distance for all cancer types over time. In general, patients experienced a physical and social burden, and higher financial costs, due to traveling extra kilometres. Patients aged >70 years travelled less often independently (56% versus 68%), as compared to patients aged ≤70 years. CONCLUSION: With nationwide centralization, travel distance increased for patients undergoing oesophageal, gastric, and pancreatic cancer surgery. Younger patients travelled longer distances and experienced a lower travel burden, as compared to elderly patients. Nevertheless, on a global scale, travel distances in the Netherlands remain limited.

Nationwide oncological networks for resection of colorectal liver metastases in the Netherlands: Differences and postoperative outcomes.

INTRODUCTION: Widespread differences in patient demographics and disease burden between hospitals for resection of colorectal liver metastases (CRLM) have been described. In the Netherlands, networks consisting of at least one tertiary referral centre and several regional hospitals have been established to optimize treatment and outcomes. The aim of this study was to assess variation in case-mix, and outcomes between these networks. METHODS: This was a population-based study including all patients who underwent CRLM resection in the Netherlands between 2014 and 2019. Variation in case-mix and outcomes between seven networks covering the whole country was evaluated. Differences in case-mix, expected 30-day major morbidity (Clavien-Dindo ≥3a) and 30-day mortality between networks were assessed. RESULTS: In total 5383 patients were included. Thirty-day major morbidity was 5.7% and 30-day mortality was 1.5%. Significant differences between networks were observed for Charlson Comorbidity Index, ASA 3+, previous liver resection, liver disease, preoperative MRI, preoperative chemotherapy, ≥3 CRLM, diameter of largest CRLM ≥55 mm, major resection, combined resection and ablation, rectal primary tumour, bilobar and extrahepatic disease. Uncorrected 30-day major morbidity ranged between 3.3% and 13.1% for hospitals, 30-day mortality ranged between 0.0% and 4.5%. Uncorrected 30-day major morbidity ranged between 4.4% and 6.0% for networks, 30-day mortality ranged between 0.0% and 2.5%. No negative outliers were observed after case-mix correction. CONCLUSION: Variation in case-mix and outcomes are considerably smaller on a network level as compared to a hospital level. Therefore, auditing is more meaningful at a network level and collaboration of hospitals within networks should be pursued.

Assessment of Preparedness of Government of Nepal in COVID Designated Hospitals and Clinics for Pandemic Response.

BACKGROUND: Preparedness, readiness, and response status of any country is integral in identifying, managing, and preventing COVID-19 pandemic. The objective of this study is to assess the status of the Government of Nepal designated COVID hospitals and COVID clinics to respond against COVID-19. METHODS: A cross sectional study was conducted with the focal persons of COVID hospitals and COVID clinics using a semi-structured questionnaire from April 26, 2020 to May 27, 2020 via face to face interview with onsite observation and telephonic interview in few unreachable health facilities.  Results: Government of Nepal designated COVID hospitals and COVID clinics demonstrated efforts in establishing preparedness plans and committees such as COVID management core team (96.7% and 86%), provision of coordination with the government authority (both 100% ), preparedness response plan (93.3% and 84%), and infection prevention and control committee (63.3% and 65.6%) to respond to COVID-19 respectively. The participants reported differences in training provided to their health care workers with maximum COVID hospitals (80%) providing training on use of personal protective equipment and least (43.3%) on handling dead bodies. Only half of the COVID clinics (49.5%) had provision of triage systems. CONCLUSIONS: COVID hospitals and COVID clinics in Nepal demonstrated different status of COVID pandemic preparedness and readiness. In case of surge, Nepalese hospitals would struggle due to lack of trained workforce and infrastructure.  Interdisciplinary, multi-sectoral collaboration with various focused strategies, including in-service training to staff, is paramount to increase preparedness and readiness.  Keywords: COVID-19; Nepal; preparedness; readiness.

Patient Mix Optimization in Admission Planning under Multitype Patients and Priority Constraints.

Hospital beds are one of the most critical medical resources. Large hospitals in China have caused bed utilization rates to exceed 100% due to long-term extra beds. To alleviate the contradiction between the supply of high-quality medical resources and the demand for hospitalization, in this paper, we address the decision of choosing a case mix for a respiratory medicine department. We aim to generate an optimal admission plan of elective patients with the stochastic length of stay and different resource consumption. We assume that we can classify elective patients according to their registration information before admission. We formulated a general integer programming model considering heterogeneous patients and introducing patient priority constraints. The mathematical model is used to generate a scientific and reasonable admission planning, determining the best admission mix for multitype patients in a period. Compared with model II that does not consider priority constraints, model I proposed in this paper is better in terms of admissions and revenue. The proposed model I can adjust the priority parameters to meet the optimal output under different goals and scenarios. The daily admission planning for each type of patient obtained by model I can be used to assist the patient admission management in large general hospitals.

Impact of the COVID-19 pandemic on the activity of the Radiological Emergency Department: the experience of the Maggiore della Carità Hospital in Novara.

PURPOSE: During the first peak of the COVID-19 pandemic, the activity of Emergency Departments worldwide changed dramatically, focusing on diagnosis and care of the Sars-Cov-2 associated disease. These major changes also involved the activity of the Emergency Radiology Department (ERD). This study aimed to analyse the impact of the COVID-19 pandemic on imaging studies, both in terms of the amount, frequency and subspecialty of different imaging modalities requested to the ERD of the Maggiore della Carità Hospital in Novara (Italy). METHODS: To this end, our observational study took into account the imaging studies requested by the emergency department during three-time spans. These were defined as phase 0 (pre-pandemic), phase 1 (pandemic peak with complete lockdown) and phase 2 (post-pandemic peak with partial lifting of restrictive measures), as derived from Italian urgent decrees by the President of the Council of Ministers (DPCM) which established the duration and entity of the lockdown measures throughout the pandemic. The dataset was processed and then compared with Pearson's chi-squared test. RESULTS: During the pandemic peak, our data showed a significant drop in the total number of studies requested and a significant rise in computed tomography (CT) studies. In particular, a statistically significant increase in chest CT studies was found, probably due to the high sensitivity of this imaging method in identifying pulmonary involvement during respiratory tract infection of possible viral etiology (SARS-Cov-2). Moreover, we observed a statistically significant decrease of X-ray (XR) and ultrasound (US) studies during phase 1 compared to phase 0 and phase 2 probably due to a reduction in the numbers of ER visits for minor traumas given the mobility restrictions and people hesitancy in visiting the ER due to fear of contagion. CONCLUSIONS: We can conclude that the activity of the ERD was heavily impacted by the SARS-Cov-2 pandemic. Further studies will be needed to estimate the impact of the pandemic on public health in terms of excess mortality related to delayed diagnosis and care of non-COVID diseases.

The Challenges of Hospitals' Planning & Control Systems: The Path toward Public Value Management.

In the last decades, public management has been subjected to a shift from the New Public Management (NPM) paradigm to the Public Value Management (PVM) one. Thus, management practices such as Planning and Control (P&C) systems have been called to evolve accordingly. The health care sector has not escaped this process. This paper focuses on the evolution of hospitals' P&C systems to support the paradigm shift from the NPM paradigm to the PVM one. In particular, the paper aims at exploring whether hospitals' P&C systems in Italy evolved, or are evolving, consistently with PVM and what are the expected benefits related to such a paradigm switch. To address the research aim, the paper is based on a review of scientific and grey literature and the case study of the diabetic-foot pathway in an Italian Regional Healthcare System. The results of this study show that the current P&C systems in Italian hospitals are not yet designed to support the shift toward the PVM approach and are still mainly focused on financial aspects and intra-organizational dynamics. Combining traditional P&Cs with performance measures assessing the system's outcomes may support hospitals in aligning their goals with the health system they are operating within and, therefore, P&C systems may represent an important driving force toward change. Such results provide suggestions for both practitioners and academics on how to adapt P&C systems to better support the implementation of current strategies of the public sector.

Trends, structural changes, and assessment of time series models for forecasting hospital discharge due to death at a Mexican tertiary care hospital.

BACKGROUND: Data on hospital discharges can be used as a valuable instrument for hospital planning and management. The quantification of deaths can be considered a measure of the effectiveness of hospital intervention, and a high percentage of hospital discharges due to death can be associated with deficiencies in the quality of hospital care. OBJECTIVE: To determine the overall percentage of hospital discharges due to death in a Mexican tertiary care hospital from its opening, to describe the characteristics of the time series generated from the monthly percentage of hospital discharges due to death and to make and evaluate predictions. METHODS: This was a retrospective study involving the medical records of 81,083 patients who were discharged from a tertiary care hospital from April 2007 to December 2019 (first 153 months of operation). The records of the first 129 months (April 2007 to December 2017) were used for the analysis and construction of the models (training dataset). In addition, the records of the last 24 months (January 2018 to December 2019) were used to evaluate the predictions made (test dataset). Structural change was identified (Chow test), ARIMA models were adjusted, predictions were estimated with and without considering the structural change, and predictions were evaluated using error indices (MAE, RMSE, MAPE, and MASE). RESULTS: The total percentage of discharges due to death was 3.41%. A structural change was observed in the time series (March 2009, p>0.001), and ARIMA(0,0,0)(1,1,2)12 with drift models were adjusted with and without consideration of the structural change. The error metrics favored the model that did not consider the structural change (MAE = 0.63, RMSE = 0.81, MAPE = 25.89%, and MASE = 0.65). CONCLUSION: Our study suggests that the ARIMA models are an adequate tool for future monitoring of the monthly percentage of hospital discharges due to death, allowing us to detect observations that depart from the described trend and identify future structural changes.

COVID-19 pandemic inpatient bed allocation planning - A Canada-wide approach.

OBJECTIVE: A Canada-wide survey was disseminated to collect information regarding changes in processes related to providing care to patients on inpatient psychiatry units in response to the COVID-19 pandemic. Our aim was to share this information with those who have an interest in problem-solving these significant and unique challenges. METHOD: The survey was distributed through the Association of Chairs of Psychiatry of Canada to Department Heads of Psychiatry at all sixteen medical schools. Information was collected via SurveyMonkey April 26-May 9, 2020. Eleven psychiatrists representing 11 different Canadian city/centre/zone(s) completed the survey. RESULTS: Information was collected about process changes: physical separation on the wards, symptom and vital signs screening, testing, isolation, rationales for number of beds allocated for COVID-positive, -suspect and -negative patients and for selecting a particular hospital to provide care to these different groupings of patients. One subsection of the information is presented in this letter. Further information is available upon request. CONCLUSION: Similarities and differences existed between city/centre/zone(s) regarding approaches to providing care to patients on inpatient psychiatry wards. Significant preparation and consideration was put into determining necessary changes in response to this pandemic, and this is reflected in the information provided from each city/centre/zone.

Bilateral internal carotid artery occlusion with compensatory perfusion in a HIV-infected patient.

BACKGROUND: Worcester Hospital is a regional healthcare facility in the Western Cape, South Africa, without a dedicated burns unit. Currently there is limited data available of burns patient management outside of academic institutions in South Africa. To describe the incidence and demographics, and to determine the outcomes of burn patients admitted to Worcester Hospital. METHODOLOGY: A retrospective descriptive study of burn patients admitted to Worcester Hospital between 1 September 2016 and 31 August 2017. RESULTS: A total of 66 burn patients were included in this study which accounted for 1.6% of the total surgical admissions for this time period. The mean age of the patients was 39 (SD ± 19) years with a male predominance (59%). The mechanism of burn was mostly flame burns (71%); 16 patients (24%) were burned with hot fluids and 3 patients (5%) sustained electrical burns. The median TBSA was 9% (IQR: 5-28). Ten patients (15%) required critical care unit admission. The burn patients' median length of stay was 6 days (IQR: 2-11 days) versus 2 days (IQR: 1-5 days) for non-burn general surgery patients. Fifty burn patients (76%) required surgical intervention comprising of either debridement or skin grafting, or a combination of this. Forty-four patients (67%) underwent skin grafting procedures and the median TBSA grafted was 5% (IQR: 3.5-9.5). The median time from admission to first surgical procedure was 25 hours (IQR: 18.33-51.08). The in-hospital mortality rate was 23% and of the 15 mortalities, 9 patients (60%) had TBSA of 30% or more and therefore classified as a major burn. CONCLUSION: Burn injuries treated at Worcester Hospital are often severe and require significant resources. This study supplies critical information regarding the burden of burn related injuries managed at a regional level.

Challenges of the Slovenian Healthcare System Exposed in Hospitals' Recovery Plans.

In recent years, Slovenian public health has been a very prominent topic, both politically and professionally. In 2017, a one-off cash transfer to hospitals from the state budget in the total amount of EUR 136.24 million cash has been ensured to pay debts to suppliers of medical materials and medicines. At the same time, emergency legislation enacted the recovery plans to ensure operational and payment stability. The in-depth analysis of the recovery plans for 15 hospitals revealed that management boards highlight the infrastructure and financial challenges as the greatest, whereas the challenges concerning the services/products and patients/users are perceived to be less important.

Critical Care Surge Capacity to Respond to the COVID-19 Pandemic in Italy: A Rapid and Affordable Solution in the Novara Hospital.

The rapid insurgence and spread of coronavirus disease 2019 (COVID-19) exceeded the limit of the intensive care unit (ICU) contingency plan of the Maggiore della Carità University Hospital (Novara, Italy) generating a crisis management condition. This brief report describes how a prompt response to the sudden request of invasive mechanical ventilation (IMV) was provided by addressing the key elements of health care system surge capacity from contingency to crisis. In a short time and at a relatively low cost, a structural modification of a hospital aisle allowed to convert the general ICU into a COVID-19 unit, increasing the number of COVID-19 critical care beds by 107%.

Contributors to the Growth of Same Day Discharge After Elective Percutaneous Coronary Intervention.

BACKGROUND: Financial pressures for reducing hospitalization costs have driven to a move toward same day discharge (SDD) following uncomplicated percutaneous coronary intervention. The UK healthcare system has transitioned to predominantly SDD for elective percutaneous coronary intervention. This study aimed to examine patient's clinical, procedural, and institutional characteristics that are associated with the increased adoption of SDD adoption over time in the United Kingdom and determine whether these vary by region. METHODS: The data were derived from the British Cardiovascular Intervention Society including all the elective percutaneous coronary intervention from 2007 to 2014 in the United Kingdom. We structured 8 meaningful groups of variables, and their relative importance was obtained by decomposing the R2 in each study year. RESULTS: The relative importance of Strategic Health Authorities was substantially higher than all other factors every year, with some reduction over time, from 49.2% (95% CI, 45.4%-52.4%) in 2007 to 43.4% (95% CI, 39.9%-46.6%) in 2014. Center volume followed with 8.95% (95% CI, 7.0%-10.9%) to 19.8% (95% CI, 16.7%-22.4%). Between patients' clinical and procedural characteristics, pharmacology and access site had the highest relative importance values, from 14.3% (95% CI, 12.1%-16.4%) to 7.1% (95% CI, 5.5%-8.8%) and from 3.6% (95% CI, 2.3%-5.1%) to 11.8% (95% CI, 9.4%-14.3%), respectively. Relative importance of different groups varied differently across Strategic Health Authorities. CONCLUSIONS: Growth of SDD was mainly associated with regional characteristics, while subcontributors varied substantially between different regions. Standardized guidelines would provide more homogenous adoption of SDD nationally. This analysis might be of wider interest in healthcare systems slower in SDD adoption.

The Role of Regional Collaboratives in Quality Improvement: Time to Organize, and How?

Over the last 12 years, surgeon representatives from the 33 participating hospitals of the Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative (MSTCVS-QC), along with data specialists, surgical and quality improvement (QI) teams, have met at least 4 times a year to improve health-care quality and outcomes of cardiac and general thoracic surgery patients. The MSTCVS-QC nature of interactive learning has allowed all members to examine current data from each site in an unblinded manner for benchmarking, learn from their findings, institute clinically meaningful changes in survival and health-related quality of life, and carefully follow the effects. These meetings have resulted in agreement on various interventions to improve patient selection, periprocedural strategies, and adherence with evidence-based directed medication regimens, Factors contributing to the quality movement across hospitals include statewide-recognized clinicians who are eager to involve themselves in QI initiatives, dedicated health-care professionals at the hospital level, trusting environments in which failure is only a temporary step on the way toward achieving QI goals, real-time analytics of accurate data, and payers who strongly support QI efforts designed to improve outcomes.

Emergency department overcrowding: Quality improvement in a Taiwan Medical Center.

BACKGROUND/PURPOSE: Overcrowding of hospital emergency departments (ED) is a worldwide health problem. The Taiwan Joint Commission on Hospital Accreditation has stressed the importance of finding solutions to overcrowding, including, reducing the number of patients with >48 h stay in the ED. Moreover, the Ministry of Health and Welfare aims at transferring non-critical patients to district or regional hospitals. We report the results of our Quality Improvement Project (QIP) on ED overcrowding, especially focusing on reducing length of stay (LOS) in ED. METHODS: For QIP, the following 3 action plans were initiated: 1) Changing the choice architecture of patients' willingness to transfer from opt-in to opt-out; 2) increasing the turnover rate of beds and daily monitoring of the number of free beds for boarding ED patients; 3) reevaluation of patients with a LOS of >32 h after the morning shift. RESULTS: Transfer rates increased minimally after implementation of this project, but the sample size was too small to achieve statistical significance. No significant increase was observed in the number of free medical beds, but discharge rates after 12 pm decreased significantly (p < 0.001). The proportion of over 48 h LOSs decreased from 4.9% to 3.7% before and after QIP implementation, respectively (p < 0.001). CONCLUSION: Patients with LOS of >32 h were reevaluated first. After QIP, the proportion of LOSs of >48 h dropped significantly. Changing the choice architecture may require further systemic effort and a longer observation duration. Higher-level administrators will need to formulate a more comprehensive bed management plan to speed up the turnover rate of free inpatient beds.