Of the many disruptions resulting from the Covid pandemic, one of the most serious for healthcare teams has been the disruption of communication pathways and relationships between team members. High turnover rates of locums and traveling staff, remote work, and masking were all contributing factors, and at many organizations, the disrupted pathways and relationships have not yet been fully restored.
This disruption has contributed to the increased length of stay that many health systems are grappling with. Other factors are at work, including bottlenecks in discharging patients to post-acute facilities and ED boarding, as well as the heightened acuity of some patients who may have delayed care. The toll is significant for organizations that cannot bring down length of stay: Kaufman Hall National Hospital Flash Report data has found several correlations between managing length of stay and financial performance.
The hospitalist’s central role
Effective management of length of stay requires consistent leadership, and hospitalists are the logical choice to fill that leadership role. The hospitalist plays an essential role in ensuring that patients stay on track in moving through the care continuum to discharge, and most health systems pay a significant subsidy for hospitalists’ service.
Length-of-stay issues may be particularly acute if hospitalists have been disengaged from care teams. Re-engaging hospitalists and rebuilding care teams depends on a disciplined focus on the factors described below.
Back to the basics
Overcoming the effects of care team breakdowns during the Covid pandemic requires a “back to the basics” approach to restore key components of effective care team relationships and length of stay management.
Multidisciplinary rounding. Multidisciplinary rounding was a casualty of the disruption of communications and relationships among care teams at organizations across the country. Multidisciplinary rounding either went away entirely or went virtual, and communications between hospitalists, nursing staff, and care coordinators became less effective.
Geographic staffing models for hospitalists and case management staff. When hospitalists or case managers/social workers are assigned to patients across multiple medical units, it is almost impossible for them to be consistently present for multidisciplinary rounding. Geographic staffing of hospitals—where a high percentage of the hospitalist’s assigned patients are in the same medical unit—overcomes that barrier and builds stronger relationships among the providers in that unit.
Estimated departure date as the driver of care. From the time a patient is admitted, the estimated departure date should drive decisions on the timing of needed care during the stay to help ensure that the estimated departure date becomes the actual departure date. The estimated departure date should be the focus of multidisciplinary rounds, so each patient is receiving the care needed that day to move them through the care continuum.
Effective utilization of APPs. Adding APPs to the care team can help observation run more efficiently and adding them to rounding teams helps improve continuity of staffing for patients, new nurses, and care transitions support.
Consistent communications with patients and families. Regularly updated communication boards in patient rooms help patients and their families understand the discharge process and encourage them to plan and be a part of the care transition to home.
Escalation pathways to the physician advisor. Sometimes doctors need to talk to doctors. Physician advisors act as the liaison between hospital administrators, case management, and physicians. Improved collaboration is needed with the shift from fee for service to value-based care. The value of care is improved through physician-to-physician discussions regarding appropriate utilization of resources (treatment and testing decisions), as well as appropriate documentation for medical necessity. These conversations are critical to changing physician practice patterns.
While these components are the foundation of a length-of-stay management initiative, the initiative’s success depends upon the full engagement and participation of all members of the care management team.
What it takes to succeed
A successful length-of-stay management initiative begins with engagement of the hospitalists, understanding their vital role in leading the care team and driving the patient’s hospital stay. Hospitalists must understand the importance of geographic staffing, including their ability to be constant and present advocates in pushing through barriers on behalf of their patients. Hospitalists also should be encouraged to assume a leadership role on their care teams, ensuring that rounds are timely and effective and demonstrating that they are worth the time that is taken away from direct patient care.
Strong nursing leadership also is an essential element of success. The nursing team should be considered partners with the hospitalists and case managers in keeping the team on track and focusing everyone’s attention on key data points around each day’s plan of care and any barriers to timely discharge that must be addressed and overcome.
As care teams are re-engaged, they must also be given the flexibility to discover what works best for the team. A particular focus here should be the format of multidisciplinary rounding: who is included, how communications are best shared among team members, how accountability for actions is assigned, and implementation of a loop closure process to verify actions items were completed. Teams should be encouraged to try multiple iterations, with input from all team members in weekly rapid plan-do-study-act (PDSA) cycles to adjust and optimize the rounding format.
Finally, key metrics at the floor level, hospital C-suite level, and system level should be defined and monitored to prioritize initiatives that support patient throughput and enable teams to quickly respond if length of stay begins to rise; examples include GM-LOS or another agreed upon benchmark, which reduces the impact of outlier cases, and helps assign an estimated departure date. The creation of hospitalist dashboards with key metric transparency will also help drive performance and throughput.
Length of stay affects so many elements of a hospital’s financial performance (e.g., volumes, revenue, margin), and it is also a key driver of patient satisfaction. By engaging hospitalists in a “back to the basics” reinvigoration of care teams—supported by the staffing models and metrics required to manage length of stay—hospitals can make real improvements that benefit both patient care and financial performance.
Case study
A recent engagement focused on length of stay improvement utilized a unique approach that puts hospitalists at the head of care team rebuilding. The engagement, involving two hospitals of approximately 600 beds each within a large health system, demonstrated the effectiveness of a “back to the basics” approach.
The hospitals were experiencing approximately 53,000 combined excess days at a combined annual loss of $28 million. By deploying the strategy and tactics described in this article, the hospitals:
- Saved 6,300 days in one quarter, with an estimated savings of $5.7 million
- Drove down the observed/expected ratio from 1.3 to 1.231
- Improved LOS from 5.4 to 5.1
- Improved hospitalist/provider satisfaction, with comments on enhanced communication among team members and a strengthened sense of community
- Improved Press Ganey patient satisfaction scores within one month
