About Raimundo Nonato Diniz Rodrigues Filho
Physician executive and intensivist with over 20 years of experience in healthcare leadership, clinical governance, quality improvement, and operational transformation.
Graduated from the Universidade Federal de Goiás, with specialization in Intensive Care at the Hospital Sírio-Libanês, MBA in Business Management from the Fundação Dom Cabral, and Master’s degree in Healthcare Administration from CBEXs/UniAlfa.
Currently serves as Director of Clinical Practice at the Hospital do Coração Anis Rassi and works on national healthcare improvement initiatives focused on Lean Healthcare, organizational maturity, emergency department overcrowding, and value-based healthcare strategies.
His work integrates clinical governance, operational efficiency, and data-driven decision-making to improve healthcare sustainability and patient outcomes in complex systems.
Recent Comments
It is already recognized that ED improvement alone will not result in reduced overcrowding, boarding, and length of stay. EDs are intertwined with downstream units, such as the ICU, ORs, PACU, and nursing wards. The output of the upstream units (EDs) becomes the input to the downstream units. Local flow improvement in separate units will not result in improved flow across the entire hospital system. When a downstream unit’s capacity is insufficient, the entire system backs up, and it is the ED that feels the consequences. Improving flow inside a single unit without addressing the downstream capacity to handle the flow just shifts the bottleneck elsewhere. A quantitative analysis of the patient flow in the hospital system from ED to discharge is needed, along with appropriate metrics. It is presented, e.g., in the book "Healthcare Management Engineering in Action", Springer, 2024 https://link.springer.com/book/10.1007/978-3-031-53663-2
in section 2.14 'The Entire Hospital System Patient Flow: Interdependency of ED, ICU, OR and NU and System Throughput.' See also section 8.5 'The expected number of patients discharged from the ED. Is the ALOS a good predictor?'
About LOS....Thank you for highlighting this point.
I agree that ALOS alone is unlikely to be a sufficiently robust predictor of near-term ED discharges. As you noted, an average can conceal substantial variability in patient trajectories and does not account for the patient’s current LOS or clinical severity.
The conditional probability approach described in your book is particularly interesting because it shifts the focus from a retrospective aggregate indicator to a more operationally useful question: given a patient’s current LOS and acuity level, what is the probability of discharge within the next defined period?
That seems highly relevant to downstream capacity planning, because predictive visibility may allow inpatient units to prepare before the disposition decision is finalized.
This also reinforces an important point for hospital governance: metrics should not only describe what happened, but help anticipate what is likely to happen next.
It is already recognized that ED improvement alone will not result in reduced overcrowding, boarding, and length of stay. EDs are intertwined with downstream units, such as the ICU, ORs, PACU, and nursing wards. The output of the upstream units (EDs) becomes the input to the downstream units. Local flow improvement in separate units will not result in improved flow across the entire hospital system. When a downstream unit’s capacity is insufficient, the entire system backs up, and it is the ED that feels the consequences. Improving flow inside a single unit without addressing the downstream capacity to handle the flow just shifts the bottleneck elsewhere. A quantitative analysis of the patient flow in the hospital system from ED to discharge is needed, along with appropriate metrics. It is presented, e.g., in the book "Healthcare Management Engineering in Action", Springer, 2024 https://link.springer.com/book/10.1007/978-3-031-53663-2
in section 2.14 'The Entire Hospital System Patient Flow: Interdependency of ED, ICU, OR and NU and System Throughput.' See also section 8.5 'The expected number of patients discharged from the ED. Is the ALOS a good predictor?'
Thank you for this very valuable contribution and for sharing the reference.
I completely agree that improving the ED in isolation is unlikely to solve overcrowding when downstream capacity remains constrained. The interdependence between the ED, ICU, operating rooms, PACU, inpatient wards, and discharge processes means that local optimization can simply relocate the bottleneck rather than improve overall system throughput.
This is precisely why I increasingly see patient flow as a hospital-wide governance issue rather than an emergency department issue alone.
Your point about quantitative analysis is particularly important. Operational visibility should not stop at identifying where delays occur; it should help us understand how capacity, variability, and throughput interact across the entire patient journey from ED arrival to discharge.
I appreciate the reference to Healthcare Management Engineering in Action. I will review the sections you mentioned, particularly the discussion on system-wide patient flow and the relationship between ED discharge and length of stay.
This systems perspective is highly relevant to the discussion we are developing around governance, Lean Healthcare, and organizational maturity.
Nice academic information
Thanks
Ms Olena and cols
One of the strongest aspects of this work is the distinction between symptom recognition and recognition of the need for professional support. In health systems, we often assume that identifying distress naturally leads to care-seeking, but the pathway is far more complex.
The concept of the “Symptom–Need Interpretation Gap” is particularly relevant because it highlights how access to care depends not only on service availability, but also on trust, stigma, cultural interpretation, family perception, and the structure of referral networks.
This discussion extends far beyond wartime Ukraine. Many health systems face similar challenges: mental health becomes increasingly visible, yet the pathways connecting schools, families, primary care, and specialized support remain fragmented or fragile.
An important contribution of this paper is showing that children’s mental health cannot be understood only at the individual level. It is deeply connected to community structures, social support, institutional coordination, and the ability of systems to transform recognition into effective access to care.
Excellent and highly relevant work.