Internal Regulation Center in hospitals: Repercussions of its implementation on the health services’ indicators

Abstract Objective To evaluate the hospital indicators and their repercussions on the number of monthly admissions to a public university hospital, before and after implementing the Internal Regulation Center. Method An evaluative research study, of the Case Study type, developed in a public university hospital. A total of 28 indicators related to structure, production, productivity and quality were measured, which are part of internal Benchmarking. The data were analyzed by means of descriptive statistics and multiple regression to identify the independent factors and those associated with the number of monthly hospitalizations with 95% confidence intervals. Results Implementation of the Center significantly increased (p<0.001) the number of discharges, the bed utilization factor and the bed renewal rate, emergency hospitalization, bed occupancy percentage, surgical procedures performed and the patient-day mean value (p=0.027). There was a reduction (p<0.001) in the number of visits to the medical, obstetric and orthopedic emergency room, in the rates of in-hospital infection and infant mortality, as well as a mean reduction of 0.81/day, approximately one day less of hospitalization per patient, or a gain of 40 available beds per month. Conclusion Although the number of available beds was lower in the post-implementation period, the bed replacement interval was reduced, representing an increase of 40 more beds per month due to the reduction in the patients’ length of stay in the institution.


Introduction
The demand for care and access to health has increased and is faced with a scenario in which the available resources, such as beds, are scarce. In view of this reality, rationalizing the hospital structure becomes a priority objective of public and private hospital institutions in order to guarantee their sustainability (1) .
The need to optimize the use of hospital beds occurs as a result of their scarcity to meet the health demands and, therefore, it becomes necessary to implement strategies to improve the performance of hospital services, with the bed occupancy rate indicator being indicated to measure efficiency and productivity in hospitals, especially public ones (2)(3)(4) .
According to the National Health Survey Bed management through the monitoring of indicators, associated with other information and governance measures, provides indispensable data to support discussions on the profile and flow of patients treated (6) , on the rational use of hospital resources and on the promotion of comprehensive health care (7) .
A study including 25 public hospitals in Iran revealed the importance of health managers acting in the implementation of strategic actions with a view to improving access and universal health coverage and, consequently, increasing the bed occupancy and bed turnover rates, as well as reducing the mean length of stay and the in-hospital mortality rate (8) .
Regarding the mean length of stay indicator, as an indicator of institutional efficiency, it is also used to dimension the bed infrastructure necessary to meet a given demand, and the shorter the length of stay, the lower the number of beds, as a greater number of patients can be hospitalized in each bed (9) .
Implementation of the IRC, in a medium and long term, results in the improvement of hospital indicators, as well as in a significant reduction in the number of patients admitted directly to the surgical center and referred to the urgency and emergency sector in the postoperative period, in addition to reducing the occurrence of patients returning to the urgency and emergency sector in the postoperative period (12) .
Considering that performance of the IRC promotes an improvement in institutional efficiency, which can be measured by monitoring the institutional performance indicators, it is correct to assert that the same indicators can be used to assess IRC effectiveness, with regard to an efficient use of inpatient beds and in regulating access to the clinical and surgical ward beds (1) . Therefore, verification of the effectiveness of the actions implemented by the IRC and its repercussions in the practices and in the care and management processes is important, especially in public university hospitals, due to the magnitude of the care services provided by these institutions and their representativeness in the implementation of the SUS Health Public Policies.
In this perspective, Benchmarking, or comparative evaluation, constitutes a recommended tool to measure health indicators, which can be adopted as a framework to internally evaluate products and work processes (internal Benchmarking) or to compare them with other services (functional Benchmarking) (13) .
With regard to internal Benchmarking, it can be operationalized through structure indicators (planned, operational, idle capacity and number of operating rooms), production indicators (number of visits, number of hospitalizations), productivity indicators (replacement interval index, mean hospital stay) and quality indicators (rate of complications, hospital infection rate), in addition to other indicators such as economic-financial and image indicators (13) .
Thus, when implementing strategies that propose changes in the management of the care work, it is recommended to use indicators to measure the results after the intervention proposed (14) and, considering that www.eerp.usp.br/rlae there is no standardization for bed management in Brazilian public hospitals (7) , this study aims at evaluating the hospital indicators and their repercussions, before and after the implementation of the Internal Regulation Center, on the number of monthly admissions to a public university hospital.

Study design
This is an evaluative survey (15) , of the Case Study type.

Period
The study was developed between January 2019 and July 2020.

Selection criteria
The study was carried out from the implementation of the IRC in a public university hospital in southern Brazil.

Study variables
The variables collected integrate the internal Benchmarking framework (13) , adopted to internally evaluate products and processes, categorized into indicators of structure, production, productivity and quality, as follows: structure -non-extra beds available; production -hospital discharges, emergency room visits (surgical, burns, medical, obstetric, orthopedic and pediatric), admissions by internal transfer, total hospitalizations, patient-day mean value, inpatient surgical patients, elective surgical patients and occupancy percentage; productivity -bed utilization factor, renewal or turnover rate, emergency and elective hospitalizations, replacement interval, mean hospital stay and surgery suspension rate; and qualitymaternal mortality ratio per 100,000, in-hospital infection rates, and general, infant, institutional and postoperative mortality rates.
It is noteworthy that these indicators and their respective classes are recognized by the Ministry of Health for the measurement and monitoring of epidemiological, quality and hospital management processes and results, subjected to data comparison at the national and international levels (11) .

Data collection
Data collection took place through the monthly report

Data treatment and analysis
After collecting and preparing the database,

Results
The comparative analysis of the IRC pre-and postimplementation phase showed a significant increase in the results of the production indicators: number of hospital discharges, bed utilization factor, bed occupancy percentage, bed renewal rate, hospitalizations from the emergency sector, number of admissions of elective surgical patients and number of surgical procedures performed.
Regarding the indicators that presented a decrease in their results, the number of visits to the medical, obstetric and orthopedic emergency room was lower in the IRC post-implementation period. The mean hospital stay, inhospital infection and infant mortality rates also presented lower values, as shown in Table 1.     The work processes developed by the IRC, based on the optimization of bed use, resulted in maintenance of the occupancy rates at satisfactory levels, with a reduction in the mean hospital stay. The result was a higher bed turnover rate and, consequently, greater availability of beds for the RAS, expanding this interface between internal and external regulation (11,16) .
With the increase in the bed turnover rate and the reduction in the replacement interval, there is also an increase in the internal transfers of patients, interunits.
Thus, an opportunity was verified to improve care processes related to patient safety in the transition of care and, this time, the hospital under study instituted SBAR as an ancillary tool to guarantee communication quality in the patient's transition between the care units (17) .
A study carried out with data from more than one million patients showed that, in addition to improving the performance of institutional indicators, adequate bed management promotes a reduction in the health services expenses (18) .
In addition to that, the authors emphasize that there is a direct relationship between the best use of the available beds and the increase in the number of hospitalizations, which is in line with the results found in the current study (18) . Therefore, it is reasserted that, in a context of insufficient hospital beds, given the growing health demand of the population, bed management practices aimed at optimizing the installed capacity make it possible to guarantee access to health care for a greater number of patients.
Corroborating the above, a study carried out with the objective of describing the results achieved in the hospital performance indicators and in the bed supply, from the incorporation of a clinic management service, including internal bed regulation by the IRC, resulted in an annual increase in the number of hospitalizations, in the number of patients discharged home, an in the bed turnover rate, and in reductions in the mean length of stay and in in-hospital mortality (7) .
In relation to the "number of hospital discharges", "bed utilization factor", "bed occupancy percentage", "number of surgical procedures performed", "number of admissions by internal transfer" and "total number of hospitalizations" indicators, they also presented an increase in the IRC post-implementation period, proving that bed management actions are the basis for optimizing the use of the available resources (7) . goal that aims at increasing access to the health service and efficiency in the use of hospital beds (19)(20) .
As a result of maximizing institutional performance through the direct action of the IRC in the internal and external regulation of available beds with a view to maintaining the occupancy rate at adequate levels and reducing the mean stay from actions linked to the management of the clinic and a responsible discharge, it is also possible to positively interfere in the reduction of costs and expenses in the health services (4) , in addition to the qualification of the care provided and patient safety (21)(22) .
With regard to the mean length of stay, studies show that a one-day reduction in the length of hospital stay, for a hospital with 300 beds, results in an expansion of the installed capacity of beds for effective use in a proportion of 49 new beds (16) . Considering that the results showed that the reduction in length of stay in the institution under study was 0.81/day, this represents an operational gain of 40 available beds each day.
Corroborating the assertion that the mean length of stay is an indicator that can be managed by the IRC, a study carried out in Thailand showed that prioritizing care, especially for aged individuals, optimizing the time between requesting and carrying out laboratory tests, and classifying the risk of the treated patients exerted a positive influence on the hospital stay indicator, reducing the number of hospitalization days and, therefore, it should be monitored to measure the performance of the emergency service (23) .
As for the "number of elective surgical patients" and "number of surgical patients admitted from the emergency sector" indicators, the bed management actions developed by the IRC in the planning and scheduling of surgeries are essential to guarantee access to the necessary care, minimizing the risk of delay and/or suspension of the scheduled surgical procedure (12) .
www.eerp.usp.br/rlae to enhance supply and access to the Brazilian (24) public health system services (25) .
As It is observed that the shorter hospital stay can be related to lower infection rates and increased access to the health system by the users. Thus, reducing the mean length of stay indicates greater problem-solving capacity for the care and management team. It is noteworthy that the mortality indicator has the characteristic of measuring care quality and, when there is a reduction, it can represent an improvement in the care provided (18) .  (7) .
Regarding the renewal or turnover rate, balancing the supply and demand of hospital services is one of the objectives of bed management (7) . In addition, bed management with the objective of using them efficiently is related to the control of hospital capacity, which allows for adequate bed turnover, in addition to ensuring patient safety (1) .  (28) .
The results presented can be precursors of a movement towards the optimization of bed management, so that elective patients enter hospitals at a moment www.eerp.usp.br/rlae