Abela, L., Pace, A., & Buttigieg, S. C. (2019). What affects length of hospital stay?

A case study
from malta. Journal of Health Organization and Management, 33(6), 714-736.
doi:http://dx.doi.org.salford.idm.oclc.org/10.1108/JHOM-10-2018-0280

Abstract
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Purpose
Hospital length of stay (LOS) is not only a function of patient- and disease-related factors, but is
also determined by other health system-wide variables. Managers and clinicians strive to achieve
the best possible trade-off between patients’ needs and efficient utilisation of hospital resources,
while also embracing ethical decision making. The purpose of this paper is to explore the
perceptions of the hospital’s major stakeholders as to what affects the duration of LOS of
inpatients.

Design/methodology/approach
Using a data-triangulated case study approach, 50 semi-structured interviews were performed
with management, doctors, nurses and patients. Additionally, the hospitals’ standard operating
procedures, which are pertinent to the subject, were also included in the thematic analysis.

Findings
This study shows that LOS is a multi-dimensional construct, which results from a complex
interplay of various inputs, processes and outcomes.

Research limitations/implications
The findings emerging from a single case study approach cannot be generalised across settings
and contexts, albeit being in line with the current literature.

Practical implications
The study concludes that a robust hospital strategy, which addresses deficient organisational
processes that may unnecessarily prolong LOS, is needed. Moreover, the hospital’s strategy
must be sustained by providing good primary care facilities within the community set-up, as well
as by providing more long-term care and rehabilitation beds to support the hospital turnover.

Originality/value
The subject of LOS in hospitals has so far been tackled in a fragmented manner. This paper
provides a comprehensive and triangulated account of the complexities surrounding the duration
in which patients are kept in hospital by key stakeholders, most of whom were hands-on in the
day-to-day running of the hospital under study.
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Introduction

Over the last decade, hospital length of stay (LOS) has increasingly come under scrutiny at a
global level, in particular following major concerns over rising health care costs and the need for
more efficient utilisation of health care services. The factors related to LOS form part of a
complex and multidimensional framework, since it is not only a function of patient and disease
related factors, but is also determined by institutional and organisational variables. Achieving a
trade-off between patients’ needs and utilisation of hospital resources, while also embracing
ethical principles in clinical decision making, is indeed becoming a major challenge for health
care managers and policy makers (Clarke and Rosen, 2001; von Eiff, 2015).

The importance of LOS and its impact on hospital resources dates back to the seventies (Lave
and Leinhardt, 1976 in Cannoodt and Knickman, 1984). Several studies have suggested that a
significant proportion of patient days in modern hospitals are inappropriate (Celik et al., 2002)
and that the cost of providing hospital services will decline if medically inappropriate patient days
are reduced or abolished (Chakravarty et al., 2005). In other words, inappropriate patient stay is
neither efficient nor effective (Panis et al., 2003).

LOS within hospitals varies widely. The adoption of lenient policies on LOS is likely to: impact on
the availability of acute beds, create bottlenecks within the hospital, decrease turnover and give
rise to waiting lists of patients expecting to be admitted. It increases the cost per stay and may
also result in hospital-acquired complications, which further delay discharge (Lim et al., 2006).
Indeed, the phenomenon of “bed blocking” emerged in the UK in the late 1950s and was used to
describe the stalled throughput for a particular bed (Manzano-Santaella, 2010), and in particular
related to older patients blocking acute hospital beds (Rubin and Davies, 1975). The term bed-
blocking – judged to be offensive and ageist – was eventually replaced by “delayed discharge”,
which describes a situation when a patient remains in hospital for care, deemed to be non-
medical, but which could be provided by social services, nursing home or home-adapted
equipment (Manzano-Santaella, 2010).

By achieving optimal LOS, hospitals release capacity within the system through the availability of
acute beds and better utilisation of staff time. This also results in better provision and planning of
hospital resources so as to address rising health care needs and lists of patients waiting to
receive acute health care. Therefore, understanding the factors contributing to LOS is crucial.

This case study will attempt to answer the following research question: RQ1.
What are the salient variables affecting LOS within Malta’s tertiary level health care?

To the authors’ knowledge, this study is the first of its kind. While the findings provide the
Maltese context-specific perceptions, Malta can be used as a case study, so as to gain a better
understanding of the variables related to the construct. This may help hospital managers to
better understand LOS strategies in tertiary level hospitals worldwide.

Background

Health care in Malta is free at the point of use, and the majority of acute emergency and elective
care is provided within the main general hospital (HIT, 2014). This tertiary care hospital was
inaugurated in 2007, and serves as the main hospital that offers medical treatment across a
range of specialities. Interventions range between life saving procedures (transplants, post CPR
events) to elective procedures such as total knee replacements, cataract removals and
laparotomies.

The current continuous development within health care, the ever-increasing patients’
expectations and the drive to provide more for less, have become top priorities for management.
Current challenges at national level include the sustainability of the present health care system to
service the increasing demands most notably due to the increase in ageing population (HIT,
2014). Other problems within the hospital set-up include a backlog of waiting lists for surgical
procedures, with typical waiting times of 24–36 months for certain procedures and long waiting
time for out-patient appointments (HIT, 2014). Overcrowding is a common scene within the
Accident and Emergency department (A&E), many times resulting in patients having to wait for
hours to be assigned a bed for admission. This has also led to overcrowding in hospital wards
with patients having to be nursed in corridors (Times of Malta, 2014). To further add to this
overcrowding problem, several beds are being occupied by long-term care patients, who occupy
a bed even though they do not require acute care as they are unable to return home following
treatment (Chetcuti and Sansone, 2013). This situation has initiated a nation-wide debate on bed
availability in order to help plan effectively for future service requirements (Sansone, 2014). For
example, better and expanded use of point-of-care testing at A&E not only results in faster
diagnosis, but may also prevent avoidable admissions (Buttigieg et al., 2015). The problem of
shortage of acute beds is also widely mentioned in UK (Richardson, 2017) and USA (Song and
Ferris, 2018) in particular as a result of the ageing population (Salonga-Reyes and Scott, 2017).
In the face of these challenging demands on hospitals, managers have turned their attention to
achieving better control of LOS by for example changing consultant job plans to include more
ward rounds that would result in reducing idle time for inpatients and therefore faster discharges
(Ahmad et al., 2011). The projections show a persistent increase in ageing populations
worldwide that necessitates international, collaborative, cross-national and cross-cultural
research to share experiences on how to prepare for this challenge across sectors including
health care (Buttigieg et al., 2015).

Theoretical background

This case study was informed by a theoretical framework proposed by Buttigieg et al. (2018)
following a scoping review on inpatient LOS. This framework follows the traditional Donabedian
(1966) structure-process-outcome paradigm, and proposes that LOS is the outcome of health
care system characteristics, hospital, patient and social/family characteristics that predict hospital
organisational processes including leadership style and team components/processes
(Pethybridge, 2004). This model also proposes that LOS may predict other outcomes, for
example hospital acquired infections and readmissions (Carey and Lin, 2014; Cosgrove et al.,
2005). So as to be able to achieve optimal LOS, hospital management should minimise the
variation of factors internal to the organisation’s structure and processes that are largely within its
control and therefore preventable, while striving to predict external factors, which are more
difficult to influence (Ginter et al., 2018). The seasonal and diurnal variations of the volume of
patients utilising A&E, in particular in circumstances of for example a severe influenza season,
pose great challenges for management to handle as these are not always as predicted (Beeknoo
and Jones, 2016). However, there are other potentially preventable variations, which develop as
a result of poor operating system designs and deficiencies in the hospital infrastructure and
processes resulting in unnecessary longer LOS (Leung et al., 1998; Rahmqvist et al., 2016).
Furthermore, acute hospital bed occupancy and turnover depend on optimal primary
gatekeeping care facilities, as well as availability of rehabilitative and long-term care beds so as
to achieve optimal utilisation of acute bed space (Buttigieg, Schuetz and Bezzina, 2016).

Methodology

Morse and Field (1996) use the principle of maximisation, emphasising the fact that a location
should be determined where the topic of study manifests itself most strongly. Based on this
principle, this study was carried out at Malta’s tertiary hospital between 2015 and 2016. At this
time, the hospital reported 950 active beds, 51,000 discharges, an average LOS of 5.1 days, bed
occupancy rate of 81.4 per cent and bed turnover rate of 77 per cent (Source: Personal
Communication, Clinical Performance Unit, Mater Dei Hospital, 2013, 2015).

A case-study approach was used for this study. Case studies are beneficial for in-depth
understanding, and insightful appreciation of a “case” resulting in new contributions to the
existing knowledge pool. Case study research goes beyond the study of isolated variables and
relevant case study data are many times likely generated through multiple sources of evidence.
All the major specialities within tertiary level care were included in this study. These include the
medical and surgical specialities, orthopaedics, neurology and neuro-surgical, cardiology and
cardio-thoracic surgery, paediatrics, critical care, obstetrics and gynaecology specialities.

Throughout this study, data from interviews, hospital data and current policy documents
pertaining to the hospital were used in order to achieve triangulation. Triangulation is the
simultaneous or sequential use of more than one data collecting technique or research method
“to tap different dimensions of the same phenomenon” (Denzel and Lincoln, 1994, p.215). The
target population included the widest range of stakeholders involved in issues related to LOS in
the hospital under study. Person data triangulation were adopted.

Purposive sampling was used in this study. This was deemed suitable, since the research
question was informed a priori, through an existing body of social theory based on literature
(Curtis et al., 2000). The cases were specifically selected as they enabled understanding of the
researched phenomenon (Coyne, 1997). Furthermore, sampling strategies in qualitative research
typically aim to represent a wide range of perspectives and experiences, rather than to replicate
their frequency in the wider population (Ziebland and McPherson, 2006). In this study,
participants were chosen from management, nursing and the medical profession, as well as from
patients. Care was taken as much as possible to achieve gender and professional background
balance amongst participants. The inclusion of patients in the study was deemed important since
their needs and expectations added to the richness of the data. Patients were chosen on a first
come first served basis as long as they fulfilled the inclusion and exclusion criteria, as well as
after having consented to participation in the study. In total, 50 interviews were carried out, and
participant demographics can be viewed in Table I. The sample enabled theoretical saturation to
be achieved, at which point when no new information or themes were observed in the data
(Guest et al., 2006).

Inclusion criteria used for management and professionals included:

 a post within the said department for at least one year; and

 willingness to participate.

Inclusion criteria for patients included:

 admission of more than 24 h;

 patients ready for discharge on day of study; and

 willingness to participate.
Exclusion criteria for patients included:

 patients discharged in less than 24 h from admission; and

 patients with communication or comprehension difficulties.

Three different interview schedules (Appendix) were compiled for management, doctors and
nurses, as well as for patients. All interview schedules were piloted prior to data collection
(Baker, 1994). Interviews were carried out by the lead author, a health care professional. The
insider role (Dwyer and Buckle, 2009) of the interviewer could prove to lead to bias; however, it
was deemed important, since the researchers’ knowledge was an asset especially when
instances of probing were necessary during the interview. Five one-to-one semi-structured
interviews were conducted with management personnel. Participants were informed that
interviews were to be audio recorded. The interviews were transcribed ad verbatim within 24 h,
and a copy was sent to the interviewee for final amendments and corrections. The above
mentioned method was again used for all professional interviews with doctors and nurses, the
only difference being that wards and speciality firms were selected initially through random
sampling, followed by purposive sampling for identification of individual professionals. Random
sampling provides the same opportunity for inclusion for each member of the target population
and, therefore, all wards and specialisations within tertiary care had the same chance of being
included in the sample (Bowling, 2009). All standard operating procedures (SOPs) of this tertiary
hospital pertaining or affecting LOS were also gathered for thematic analysis.

Table II summarises traditionally used objective measures from quantitative methodologies and
their proxy trustworthiness equivalents used in qualitative methods. It also highlights strategies
used in this research study to ensure trustworthiness.

All necessary permissions from all departmental chaipersons and the hospital CEO were
obtained together with approval from the ethics committee of the Faculty of Health Sciences and
University of Malta. Confidentiality, anonymity and voluntary participation were emphasised in the
invitation sent to all participants and written consents were required prior to participation. Data
gathered throughout this research were solely used for research purposes and all participants
were informed about this, prior to initiation of data collection. All participants were given a code to
ensure confidentiality and anonymity (Table II).

Data were analysed thematically as part of content analysis. This involved the collection of data,
which were then coded by theme or category and finally analysed and presented (Bowling,
2009). Thematic analysis is a qualitative analytic method for identifying, analysing and reporting
patterns (themes) within data. Thematic analysis goes beyond organising and describing data in
rich detail, as it also interprets various aspects of the themes (Braun and Clarke, 2006). Thematic
analysis was performed using QDA Miner 4 Lite by Provalis® research.

Findings

The results of this case study show that a total of ten themes and their respective categories
emerged from the content analysis. Figure 1 organises these concepts following the model
proposed by Buttigieg et al. (2018), and therefore conforms to the systems model of hospital
structure, processes and outcomes. Figure 1 reflects the findings of the specific hospital context
in Malta as part of the case study.

The emerging themes were health care system characteristics, hospital characteristics, patient
and social characteristics, organisational processes, leadership, team components and
processes, use of resources, hospital acquired infections and complications, readmissions and
patient satisfaction and outcomes. These themes were then considered as a part of structure,
processes and outcomes as follows.

Hospital structure

Tertiary care hospital structure supports the efficient and effective delivery of hospital services
whilst allowing for variations in care required within the diverse spectrum of patient requirements.
Three themes emerged under this heading, namely health care system attributes, hospital
characteristics and patient and social characteristics.

Health care system attributes

The Maltese health care system in Malta faces similar pressures as other developed countries, in
particular those related to sustainability of the health system and those resulting from the ageing
population. Of relevance to inpatients’ LOS is the level of support services that exist outside
hospital. These include primary care to all age groups and long-term care for the older patients,
who are not able to be discharged back to their homes. LOS also depends on the support
provided by the servicing departments such as the medical imaging department and laboratory
services. Delays in providing timely investigations and results will impact LOS, resulting in
delayed discharges.

Hospital characteristics

The hospital under study faces a number of undesirable situations ranging from shortage of
beds, to an increased number of patients attending A&E, to increased boarding time in the said
department due to lack of available beds for admissions. Patients admitted to the wards arrive
via three possible routes, from A&E department, patients admitted from home for elective
procedures, and patients admitted directly from out-patients department. The latter two still have
to go through A&E for registration of the admission process. The different channels and acuity of
presenting conditions determine not only the extent to which patients are prepared for admission,
but also the duration of the LOS. Elective and emergency admissions have different needs and
requirements. Emergency admissions are erratic and create increased system demands
requiring prompt and efficient interventions. These interventions will only result in effective
outcomes if the required processes are in place, they are user friendly and run in-parallel to
promote smooth running of the patient pathways. On the other hand elective admissions can be
planned in advance and should follow a pathway already in place unless complications arise.

Patient and social characteristics

Patients are the main clients within a hospital and their attributes, requirements and needs, will
set standards of quality and will help in developing efficient and effective services. Patients’ and
relatives’ demands and expectations of care are continuously influenced by their socio-economic,
cultural and education levels. Nowadays, information on medical conditions and procedures is
readily available and accessible, and the patient has an active role in decision making throughout
his care pathway. The link that exists between patient, social characteristics and LOS was clearly
expressed by most of the stakeholders, as highlighted in Table III, which shows the quotes from
the interviews for theme 1, as linked to the effect on LOS and to the literature.

Figure 2 shows the frequency distribution or variables as gathered from interviews, for the
different categories mentioned within this theme. It shows that patient and social characteristics
followed by health care system attributes and hospital characteristics as being the most
frequently mentioned and therefore considered the most important by participants.

Hospital processes

Tertiary care processes incorporate mechanisms arising from the combination of organisational
and professional processes. Ideally, these processes produce outcomes which are efficient,
effective and should result in optimal patient care, only and when these processes are
undertaken via effective leadership and with good management support. Three themes emerged
under this heading, namely organisational processes, leadership and team components and
processes.

Organisational processes

Organisational processes are numerous and of a rather complex nature within any organisation,
and hospitals are no exception. Many times, processes are dependent on each other or move in
parallel to each other. Complex organisations like hospitals require a clear vision that highlights
the direction of the organisations’ mission – focused on delivering patient-centred care – and all
processes should directly or indirectly help towards achieving this mission. The salient processes
that impact LOS and that were mentioned by participants were standardisation of processes
across specialities and departments, well-structured and organised discharge planning, and the
lack of activity during weekends and public holidays. Hospital practices vary widely across
departments, and standardisation seems to be lacking within the hospital, with different
specialities using different procedures and treatments for similar patient conditions. Major
differences in working procedures were noted by the participants. Various guidelines and
protocols exist throughout the various specialities within the hospital however there is no one
available patient pathway which describes the journey of the patient from admission to discharge.
Discharge planning is a crucial event for every admission, however it is many times left for the
last day and at times the patient is totally unprepared to go home. Unplanned discharge is one of
the causes leading to unnecessary readmissions. From the interviews with patients it emerged
that during weekends and public holidays the hospital goes on “slow mode” and only the
necessary activities are performed. Table IV shows the quotes from the interviews for Theme 2,
which are then linked to the effect on LOS and to the literature.

Leadership

Various aspects of leadership were highlighted during the interviews, and these included
reluctance for change, lack of sufficient proactivity on behalf of people in leadership positions and
public service’s challenges when it comes to recruitment and selection.

Team components and processes

The interviews showed that there is no structured multidisciplinary teamworking. Within the
hospital under study, teams are in their majority consultant-led. There is very little set time for
team meetings and this happens when ever, ad hoc.

Figure 3 shows the team components and processes, followed by organisational processes and
leadership as being the most frequently mentioned by participants. Of interest is the highly
mentioned sub-category of standardisation across specialties and departments, which seems to
concern the participants as resulting into too much variation and therefore which can be
improved.

Hospital outcomes

Hospital care outcomes are determined by a number of factors, with the most predominant
factors mentioned by participants apart from LOS – as the major subject under study, being bed
use and bed-blocking, efficient use of resources, readmissions and patient satisfaction and
outcomes. Table V shows the quotes from the interviews for Theme 3, which are then linked to
the effect on LOS and to the literature.

Four themes emerged, namely bed management, hospital acquired infections, complications and
adverse events, readmissions and patient satisfaction and outcomes.

Bed management

Beds are crucial resources within tertiary care hospitals and there seems to be consensus
amongst participants about the importance of beds’ efficient use so as not to experience bed
blocking.

Hospital acquired infections, complications and adverse events

The hospital’s infection control unit has raised the awareness of staff on the dangers of acquired
infections for example MRSA, C. difficile, Klebsiella and E. coli. Hand hygiene is being given
prominence in education, hospital policies and audits. As regards hospital acquired complications
and adverse events, the ones mentioned are pressure injuries, deep vein thrombosis, pulmonary
embolism, respiratory complications and medication complications. The case study revealed that
more clinical audits need to be in place to keep these in check. There was consensus among
participants that hospital acquired infections, complications and adverse events have a dramatic
effect on patients’ LOS such that it was acknowledged that the hospital would do well to invest
more on their prevention.

Readmissions

Readmissions were scarcely mentioned by participants, who blamed lack of support within the
community and lack of compliance on the patients’ part as what they believe are the main
causes. Interestingly, the participants did not relate LOS with readmissions.

Patient satisfaction and outcomes

From the data gathered during patient interviews, the majority were very satisfied with the
treatment and service provided. The link with LOS was what patients referred to early discharge,
when there was lingering symptomatology and insufficient support in community.

Frequency of these factors as mentioned during the interviews is displayed in Figure 4.

Discussion

This study contributes to knowledge as it sheds light on issues that impact inpatients’ LOS.
Specifically, it shows challenges faced by hospitals in small states like Malta with few fall-back
contingency plans and with limited resources. The themes and categories emerging from the
case study are in line with the theoretical framework developed from the scoping review by
Buttigieg et al. (2018), thereby reaffirming the multidimensionality of the construct. They are also
in line with the vast literature on the subject.

LOS is related to inputs, processes and outcomes, which were presented in the findings as the
three main emerging themes. This study reaffirms the shift of health care performance
management from being output and outcome based to adopting a system-based approach
(Buttigieg, Gauci and Dey, 2016). From within these themes, the most salient categories
mentioned were hospital characteristics, patient and social characteristics, organisational
processes, leadership, team components and efficient use of resources. However, a striking
finding was that readmissions and complications were minimally mentioned by participants in
contrast to the literature. Therefore, these two important variables were being underestimated by
the study’s participants.

The lack of availability of community services were mentioned throughout. These emergent
findings clearly show that support services within the community together with continuity of care
are critical during the patient’s transition from acute care back to the community. Another
important point was that the family should be involved as early as possible during the admission
and community services should be expanded through provision of domiciliary nurses and health
professionals. These visit patients especially those with chronic conditions, thereby providing
domiciliary support and limiting admissions to the acute set-up (McHugh et al., 2009). The
availability of 24-h community support back-up was another important issue. Due to the lack of
community support especially after office hours, patients with social problems have to be
admitted as in-patients until these problems are sorted out. “Hospital at home” is another option
lately being mentioned throughout the literature. A study by Caplan et al. (2012) showed lower
costs, shorter duration of hospital-equivalent care, reduced geriatric complications and improved
activities of daily living and better patient and caregiver satisfaction. This fairly new concept
provides basic procedures which are hospital based, but which however, can be carried out
within the home by professional personnel. Procedures such as intra-venous antibiotic
administration or management of wounds can be safely performed. This will benefit many
patients as at times patients are kept only for administration of treatment.

One major hospital characteristic that emerged from the study was boarding time in A&E. Time in
A&E is widely mentioned in the literature as having an effect on LOS (White and Glazier, 2011;
Sun et al., 2013). Reasons for the increased boarding time vary across hospitals. Throughout the
literature, many plausible options for this delay were explored (Earnest et al., 2006; Hoot and
Aronsky, 2008). However, within this hospital, the major difficulty seems to be the lack of
available beds for admission within the wards, which is therefore decreasing the hospital turnover
rate. Other issues mentioned, which are also affecting the hospital turnover rate are the
unavailability of senior staff capable of discharging patients during weekends and public holidays.
In addition, there is slower processing of patients after normal working hours due to lack of
human resources available.

Every organisation requires some sort of support services, and hospitals are no different.
Hospitals require the constant support of radiological departments, laboratories, allied health
professional groups and other support staff (White and Glazier, 2011). However, the need for
such services was very poorly mentioned during the interviews and interviewees were inclined to
minimise the importance of such services in terms of their effect on LOS. On the other hand,
support services are known to be the building blocks within patients’ pathways (Brusco et al.,
2007). Since no patient pathway is available, support services’ requirements are only performed
upon request by the consultant involved and, therefore, there is no established practice which is
automatic upon admission for a particular patient. Thus, if a patient is admitted during the
weekend he/she will probably have to wait till the next working day for the support services to be
requested.

Theme 2 encompassed the tertiary care hospital processes with the main categories being
organisational processes, leadership and team components. One of the categories which was
highlighted several times was that the staff lacked clear aims and objectives. This should be
clearly established within any organisation and all staff members should be made aware of the
organisation’s mission. This will motivate personnel and give them a target to work towards.
Hospitals are not organisations that are easy to work in, and personnel within these set-ups need
to be dedicated. However, if their work and effort is not appreciated they can easily become
demotivated (Cho et al., 2014). The most salient variable mentioned by almost every stakeholder
within organisational processes was standardisation between different specialities.
Standardisation within this hospital seems to be lacking. There are variations in work procedures,
and documentation is standardized only for that particular set-up. Patient pathways for specific
conditions are almost non-existent and many times they depend upon and are according to the
consultants’ decisions. Ward rounds, which should be organised consistently (Ahmad et al.,
2011; Soliman et al., 2013), are performed haphazardly, and every firm or speciality seems to
decide ad hoc when to perform them. On Sundays and public holidays, these situations are
further augmented with the loss of the consultants’ decision powers and patients remaining in
hospital awaiting such decisions. Furthermore, in times of bed constraints, patients are admitted
anywhere in hospital with resultant cohorts of different patient specialities in the same wards.
This practice may give rise to sub-optimal outcomes (Stowell et al., 2013). At times, this results in
duplication of work procedures and delays, and lack of continuity of care or mismanagement
throughout patients’ pathway (Ivey, 2006). Apart from prolonging LOS, this is a source of
frustration among health professionals who have to constantly deal with these issues whilst trying
to provide optimal care. This can also result in adverse events and procedure errors (D’Amour et
al., 2014).

Communication was another salient variable within organisational processes, which was
mentioned by most of the stakeholders, including patients. Interprofessional collaboration and
communication are the key for improving quality and safety of patient care (Institute of Medicine,
2011). Considering the complexity of the hospital organisation and the unstructured manner in
which ward rounds are organised, opportunities for effective communication are difficult to find.
Many informal meetings combined with multiple and often duplicate forms of documentation
result in redundant and ineffective communication (Gotlib Conn et al., 2012). This has a negative
impact since it results in lack of coordination, which is frequently associated with adverse events
and patient harm (Schmutz and Manser, 2013).

Literature also questions physicians’ disengagement from communication, which was evident in
this study, as it interferes with achieving efficient hospital stays and discharge of patients.
Furthermore, this lack of physician communication demoralises non-physician staff and
contributes to unnecessary frustration (Zwarenstein et al., 2013). Patients also expressed their
concern about the lack of communication with their consultant. Some patients were also unaware
of their medical conditions. It is therefore recommended that ward rounds should be more
formalised and preferably at set times. This will provide a reference point for patients to meet
their consultants and will also allow interdisciplinary interaction.

Literature highlights the importance of team processes, which is central to the successful
provision of patient care (Nancarrow et al., 2013). However, from the interviews, it was evident
that each profession worked separately rather than as an interdisciplinary team.

Difficulties, which were encountered during discharge, were also mentioned by many
stakeholders. Evidence from the literature shows that proper discharge planning, especially for
older patients, reduces hospital readmissions and readmission LOS (Fox et al., 2013).

Issues relating to leadership were mentioned mostly by management personnel. Traits for good
leadership were explained; however, the difficulties encountered by leaders within the hospital
were also expressed. These included the resistance to change by personnel and also the failure
of the organisation to tackle certain professional behaviours especially when professional bodies
such as trade unions step in. The literature defines leadership as not merely a role to maintain
high standards of care, but also as an opportunity to transform services to achieve even higher
levels of excellence (Department of Health, 2008). It is therefore the role of the organisation to
provide optimal grounds for these leaders to work in and to achieve the required optimal results.
Theme 3 reflected the stakeholders’ views of tertiary care hospital outcomes. All participants
were aware that LOS is affected by bed-blocking and has an influence on efficient use of
resources. However, one striking finding was that both hospital acquired infections and
complications, as well as readmissions were the least mentioned. Hospital acquired infections or
complications can result in a two-fold increase in LOS (Lagoe et al., 2011) with a substantial
amount of hospital resources including bed-days being lost to such events (Graves et al., 2005).
Within this hospital set-up, the latest reports on readmissions which were issued in 2013, have
identified medical respiratory patients as having the highest readmission rates. This suggests
that there is room for improvement in this area, especially within the medical fields, even though,
these readmissions were least mentioned in the interviews. These high readmission rates may
implicate organisational problems in the management of patients suffering from respiratory
conditions. This, therefore, established a gap in the knowledge of the stakeholders.

Although this study has various strengths and various strategies were employed to ensure rigour,
it still has some limitations. The insider role of the researcher may have been a limitation since
participants could have assumed similarity in their trail of thinking and thus failed to fully explain
their individual experience. Furthermore, the researchers’ perception might also be clouded by
personal experiences which make it difficult to separate from that of participants, thus shaping
interviews according to the researchers’ views (Corbin Dwyer and Buckle, 2009). In addition,
results could have been easily influenced by personal biases and idiosyncrasies. Another
disadvantage of the qualitative approach is that findings cannot be extended to wider populations
with the same degree of certainty that quantitative analyses can. This is because the findings of
the research are not tested to discover whether they are statistically significant or due to chance
(Ochieng, 2009). The whole research project was described in detail so that readers can make
their own judgment whether findings are transferable or not (Shenton, 2004).

Implications and recommendations

This study has identified a substantial number of factors that have an effect on LOS within the
Maltese set-up, which were in accordance with literature findings. This study has also identified
that all stakeholders are aware of the importance of LOS; however, their interpretation of the
construct varies. Individuals in management roles were aware that factors affecting LOS, such as
bed-blocking and bed shortage in rehabilitation or long-term facilities together with possible
solutions to free beds at a faster rate, need to be high on the agenda. However, at clinical level,
clinicians’ main concern was providing patient care rather than focusing on LOS and shortage of
beds – which they considered as the management’s prerogative to solve. This research
highlighted that LOS is related to various inputs and processes and resulting into outcomes as
illustrated in Figure 1. At policy level this was also complimented through SOPs currently in place
within the hospital, aiming at influencing LOS. The availability of LOS as a key performance
indicator shows management’s commitment in trying to improve processes based on objective
data measures. However, LOS also reflects the stability within the organisation, which should
embrace a clear long-term strategy that must be supported by the necessary infrastructure within
the whole health sector. A common salient variable, which was mentioned by all stakeholders,
both from management, clinical personnel and also from patients, was the lack of organisation
and support available within the community. This lack of community support affects the need, the
pathways and the outcomes of admissions to hospital, as illustrated in the systems model. The
need to support and educate patients through the provision of good, comprehensible, affordable
and easy to access community services would provide target solutions for many of the variables
mentioned that have an effect on LOS. This proves that good support within the community is
imperative and until this is taken up on the health agenda, our hospitals will remain full of patients
being readmitted unnecessarily.

Uptake of outreach services upon discharge for the different specialities within the hospital
should be further explored. This has already proved to be effective within the orthopaedic
speciality in the case under study, and should be performed in liaison with the discharge liaison
nurses. Organisational processes within the hospital are the cause for concern for many of the
stakeholders interviewed. Lack of standardisation across the different specialities was a main
cause for concern. Practices change according to speciality, and therefore can be confusing
especially to professionals, who interact with the different specialities within a ward set-up.
Despite the introduction of the discharge liaison nurses and the discharge facilitation team in the
hospital under study, discharge planning appears still to be lacking and many times it is thought
about on the last day before discharge, with undesired consequences. Clinical personnel agreed
on the fact that discharge planning should be tackled from day one of admission and should be
discussed during ward rounds that should be performed routinely with all professionals.

This study therefore contributes to practical knowledge as it applies the theoretical framework
developed by Buttigieg et al. (2018) to the case under study. It also highlights an example
whereby stakeholders in specific contexts may not perceive certain variables associated with
LOS as salient. Nevertheless, this study provides a comprehensive and triangulated account by
key stakeholders, most of whom are hands-on in the day-to-day running of the hospital under
study, of the complexities surrounding the duration in which patients are kept in this hospital.

Figure 1
Model reflecting emerging themes from this case study and adapted from the theoretical
framework by Buttigieg et al. (2018)

Figure 2
Theme 1: hospital structure
Figure 3
Theme 2: hospital processes

Figure 4
Theme 3: hospital outcomes

Table I
Demographic data of participants

Professions Gender Codes

Management Manager(2) Males(2) E1, E2, E3, E4, E5

interviews

Consultants(3) Males(3)

Speciality interviews

Cardiac Services Nurse(1) Female(1) Doctors: D1, D2, D3, D4, D5,
Doctor(1) Male(1) D6Nurses: N1, N2, N3, N4, N5,
N6, N7

Medical Nurses(2) Males(2)

Doctor (1) Female(1)
 Professions Gender Codes

Surgical Nurse(1) Female(1)

Doctor(1) Male(1)

Neurology Doctor(1) Female(1)

Paediatrics Nurse(1) Female(1)

Doctor(1) Male(1)

Critical care Nurse(1) Female(1)

A&E Dept. Doctor(1) Male(1)

Orthopaedics Nurse(1) Males(1)

Patients 30 Females(12) P1–P30

Males(18)

Table II
Rigour and reliability in qualitative research

Traditional Trustworthiness Methods for meeting trustworthiness criteria

Internal Credibility Data triangulation was obtained as data were collated

validity from interviews, hospital statistics on LOS for the years
2013/2014, together with documentation at policy
levelPerson triangulation was also used since three
groups of participants were interviewed consisting of
management, health care professionals and
patients.Each participant was sent a copy of the
interview for confirmation

External Transferability A detailed description of the structures and processes

validity relating to context in the data are provided in the paper

Reliability Dependability Purposive sampling was usedThe participants

confidentiality was protected at all times by assigning
codes

Objectivity Confirmability Data were managed and recorded meticulouslyAll the

interviews were transcribed ad verbatim within 24 h of
the interviews

Source: Adapted from Lincoln and Guba (1985) in Shah and Corley (2006)

Table III
Quotes that justify themes and subthemes under structure, and link to LOS
Theme Sub-themes Quotes Relation to length of
hospital stay

Health care Support services (i) “A patient with Hospital care depends not
system within and (ii) abdominal pain, only on specialized care
attributes outside the hospital: they think it is but also on efficiency of
(i) all the ancillary cholecystitis, they servicing departments
services to establish want to do an MRI within hospital. (White
diagnosis and to admit for ERCP; and Glazier, 2011).
optimal treatment […] leave him Furthermore, for the
plan (laboratories, awaiting for ERCP patients to be discharged
the medical imaging and may wait for 3- safely, care needs to be
and the paramedic 4 days for MRI” continued in the
services)Hospital N3SOP community. If this is
management issued (med01sop2013) lacking, then discharge
SOPs on timely “all newly issued planning needs to take this
procedures(ii) Need results are flagged into account (Fox et al.,
for integrated care, and seen by a 2013; McHugh et al.,
and community doctor in a timely 2009). Older adults
carers. GPs do not fashion, decreasing awaiting long-
have sufficient the chances of term care has prolonged
investigative powers, missed results, LOS (Salonga-Reyes and
and prone to refer to allowing for more Scott, 2017)
A&EIncrease in efficiency and
older patients flagged safety in patient
for long-term management”
care/rehabilitation p.1“We depend on
servicing
departments to
secure timely
discharges” D2“A
home visit by nurse
and physio after
discharge, sets their
mind at rest”
N1“GPs are risk
averse. I think
everybody is afraid
[…]. you can be
accused of
negligence” E3“A
few years ago we
had a waiting list of
around 700 elderly
to enter into long-
Theme Sub-themes Quotes Relation to length of
hospital stay

term care. Now it’s

gone up to 2800”
E3“We need co-
ordination of
integrated care in
the community” E4

Hospital Hospital organisation “A lot of decisions Hospital strategic

characteristics structure: Malta’s that matter are decisions/operating
tertiary hospital dependent on the systems influence
relies on decisions Ministry of Health efficiency/effectiveness of
taken at ministry e.g. we identified care, and resources for
level and this at certain medicines clinicians to act swiftly
times conflicts with that, if we give (Ginter et al., 2018)
the hospital’s them to the patients,
strategic priorities we reduce LOS by
(HIT, 2014, p. 19) up to 3-4 days, but
these medicines
were not approved
by the Ministry of
Health”
E1“management is
constantly in crisis -
constantly trying to
sort out the day-to-
day bed situation in
the hospital” E5

Boarding time at “For 6 hours I was Delay in transfer to ward

A&E: boarding time in A&E until I was results in delay to start
is the time spent in transferred to specialized care (Sun et
the A&E department corridor. I could al., 2013)
until they are hardly move and
transferred to a ward the corridor was full
of other patients,
Theme Sub-themes Quotes Relation to length of
hospital stay

almost touching
each other. After
another day in this
situation I was
transferred to a
proper ward” P15

Differences in “As things stand to- Overcrowding and long

admissions from date admissions waiting times, compromise
different pass through A&E emergencies and are due
channels:Patients department, to non-urgent visits,
admitted to the wards sometimes people frequent-flyer patients,
arrive from A & E, just pop in at A&E, inadequate staffing,
home for elective Some patients are inpatient boarding and
procedures, and referred away” hospital bed shortage
directly from out- D1“All our elective (Hoot and Aronsky, 2008)
patients department patients go through
the Pre-assessment
clinic” N1“there is
a big difference.
When they come
from home they are
planned, they would
even know what to
get with them,
however when from
A&E we wouldn't
even know” N1

Patient and Support from family “When patients The link of family support
social and community care identify well with with LOS has been studied
characteristics services their GP, it is in stroke patients (Mant et
always easier to al., 2000)
discharge” D4
“LOS depends on
 Theme Sub-themes Quotes Relation to length of
hospital stay

the support from the

family and
community.” N1

Table IV
Quotes that justify themes and subthemes under processes, with link to LOS

Theme Sub-themes Quotes Relation to length of

hospital stay

Organisational Standardisation across “If a patient comes Variations in

processes specialities and in with pneumonia, consultants’ decision
departments: hospital one consultant making on duration of
practices vary widely, would discharge the LOS (McPherson,
and standardisation patient after 3-5 1990). When patients
seems to be lacking days. another are not admitted to
within the hospital, consultant 10-12 dedicated and
with different days” E2“This is a specialized wards,
specialities using female surgical precious time is lost,
different procedures ward, so we admit prolonging LOS as
and treatments for only females under staff are not adequately
similar patient surgical consultants; trained to care for the
conditions.In times of but when medical, idiosyncrasies of the
bed shortages, certain ENT and Gynae condition (Boddaert et
wards may have to wards are full, we al., 2014)
admit other specialities admit those patients
as well” N3“We do
use guidelines but it
depends on the case
[…]” D4
Theme Sub-themes Quotes Relation to length of
hospital stay

Discharge planning: “Sometimes we get When discharge

discharge planning is a patients who are planning is in place,
crucial event for every discharged and we LOS is predetermined
admission. Unplanned receive a call and the team of health
discharge is one of the informing us that the care professionals can
causes leading to relatives cannot take structure their
unnecessary the patient back management plan to fit
readmissions.When, home” N7“Yes, the the time period.
and where, proper doctors and nurses Relatives will also be
information is given to explained to me informed of the plan
patients/relatives, what I have to do (Fox et al., 2013)
discharge should be an and I will also be
uneventful step in given a booklet with
patient pathway information to
follow on discharge”
P1

Activity during “On Sunday the This ‘slow mode’

weekends and public ward environment is activity during
holidays: From calmer with only a weekends and public
interviews with patients few doctors. I think holidays hinders
and management, it only the very discharges and
emerged that during necessary things are prolongs LOS during
weekends and public done” P14“When this period, due to lack
holidays the hospital there are no ward of ward rounds (Lewis
goes on “slow mode” rounds, there are no and Edwards, 2015).
and only the necessary discharges. During
things are performed weekends and public
holidays patients are
rarely discharged”
N6

Leadership The reluctance for “Change leads to Leadership is important

change and lack of uncertainty and we to influence team
proactivity of people in live in a culture of members to work
 Theme Sub-themes Quotes Relation to length of
hospital stay

leadership positions. uncertainty towards a common

Also management avoidance” E5“We goal, and to be efficient
difficulties when it are quite in achieving the
comes to removing disempowered in optimal LOS
people from certain tackling those (Pethybridge, 2004)
positions consultants who are
creating LOS longer
than necessary and
that’s where the
problems are” E1

Team No structured “There is no Poor teamwork creates

components multidisciplinary multidisciplinary problems when it
and processes teamwork: within the team […] we do not comes to
hospital the team is take joint decisions. continuation/change in
consultant-led and We don’t assess treatment and patient
he/she takes the major patients together and handover from doctors
decisions with or we don’t discuss to nurses (Iedema and
without consultation patients on a formal Merrick, 2016). Certain
with other team basis” D4“Since we issues are being
members. There is very are the biggest ward overseen, neglected or
little set time for team with 32 patients, forgotten. This leads to
meetings and this ward rounds are all delayed discharge and
happens ad hoc over. There is no prolonged LOS
specific time” N4

Table V
Quotes that justify themes and subthemes under outcomes, with link to LOS
Theme Sub-themes Quotes Relation to length of
hospital stay

Use of Bed use: efficient timing “You have to fight Delayed discharges
resources of discharges and for every bed all the happen when patients
admissionsBed time” E3“We are occupy beds for non-
blocking:Lack of support not turning over medical reasons. This
from primary care and beds as much as we prolongs LOS and the
long-term/rehabilitative really can, and that caring clinicians are
care will result in beds creates bottlenecks powerless in these
blocked due to delayed in the influx of situationsEfficient use
discharges.Lack of patients especially of resources impacts
Support from family and in the Winter LOS (Thampi et al.,
community care services. months, so it is a 2015)
Correct use of equipment, problem” E1“Some
devices and hospital people do not care.
resources will provide If e.g. a laparoscopy
desired outcomes and will instrument breaks
not jeopardise timely due to carelessness,
delivery of care you wasted 5000
euros” E3“Health
care is not a
bottomless pit” D6

Hospital Hospital acquired “We are more The differences in

acquired infections: MRSA, C. aware now of hand LOS for patients with
conditions difficile, Klebsiella, E. hygiene, we may the same diagnosis
coliHospital acquired transmit infections with or without
complications for example from patient to infections is
pressure injuries, deep patient” D6“Length substantial (Lagoe et
vein thrombosis, of stay is heavily al., 2011). In
pulmonary embolism, dependent on the particular MRSA
respiratory complications, patient’s condition bacteremia is
and medication and comorbidities associated with
complicationsAdverse […] a patient was significant increase in
events:patient safety really doing well, LOS (Cosgrove et al.,
issues now he has bilateral 2005). Medical
pulmonary injuries lead to excess
embolism. This will LOS (Zhan and
take a lot of time to
stabilize the patient
until he is ready for
Theme Sub-themes Quotes Relation to length of
hospital stay

discharge” Miller, 2003)

N1“Early
mobilization is very
important for earlier
discharge and the
less the
complications.”
N6“We do have,
although rarely,
issues like falls,
medication errors.
These definitely not
only prolong LOS
but they are the
worrying cases
[…]” D2

Readmissions Readmissions “Repeatedly To improve the value

patients do not in the delivery of
comply with expensive inpatient
treatment in COPD care, readmissions
and in heart failure. should be avoided
So, patients slowly (Carey and Lin, 2014)
deteriorate, their
respiratory rate
starts to go up, their
saturation worsens
and they end up in
hospital. In Malta
we have
COPD/COAD
patients, around
48% of whom are
readmitted within 3
months” E3
 Theme Sub-themes Quotes Relation to length of
hospital stay

Patient From the data gathered “the service is very Early discharge from
satisfaction during patient interviews, good […]” P7“I am hospital, if supported,
and outcomes the majority were very not satisfied at all has been associated
satisfied with the since after 7 days with patient
treatment and service admission, I am still satisfaction
given. Some complained in pain and I am (Sibbern et al., 2017)
about early discharge unaware of the
cause and I was
discharged today”
P5“Not very good. I
am still feeling
unwell and doctor
wants to send me
back to the nursing
home” P22“Not
very good. They
want to send me
home. I live alone, I
have stairs at home,
am in a wheelchair
and cannot cope”
P16

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