A patient gets admitted for evaluation. The attending orders a consult. That specialist recommends a test and the test identifies an incidental finding that needs further workup. As a clinician myself, I appreciate that each step feels justified at the time, but together they stretch what should be a three-day stay into five or six. These delays add up fast, clogging beds, frustrating boarding patients in the ER, and driving up costs across the board.
Length of stay (LOS) reflects how efficiently a hospital runs and how well it cares for patients. But keeping it under control means dealing with some thorny incentives. Hospitals often get paid a flat bundled rate, so every extra test and incremental labor cost comes straight out of their pocket. Yet doctors and patients usually prefer to complete the full workup while the patient is already there, even when it would be just as safe and much cheaper to handle non-urgent tests as an outpatient.
Hospitals have tried everything to bring down hospital LOS. Discharge-before-noon campaigns. Blanket restrictions on consults. Tightly controlled care pathways. Yet these interventions rarely move the needle. In fact, studies reveal a troubling paradox: we’ve expanded imaging capacity to speed up care, but both imaging rates and average length of stay have climbed right alongside it.
These failures share a common theme: they focus on workflow and processes rather than clinical decision-making. Recognizing the role of clinical decision-making can empower healthcare stakeholders dealing with throughput challenges to implement more effective strategies that truly impact patient care and LOS.
In the outpatient world, payors have long recognized that utilization management is one of the most powerful levers for controlling costs. Hospitals rarely apply such mechanisms internally due to friction between administrative teams focused on efficiency and clinical teams focused on patient care. The result is a false dichotomy pitting financial stewardship against clinical excellence.
It doesn’t have to be this way. Variation in decision-making between similarly trained clinicians offers the most powerful bridge between administrators and clinicians. When hospitalists discover that colleagues treating similar patients order MRIs at vastly different rates, or that consult utilization varies twofold across teams, the implications become clear. At this population-level evaluation, patient acuity alone can’t explain these gaps.
Suddenly the conversation shifts from rationing to standardization; from an individual clinician’s autonomy to a teachable moment on peer clinical practice. The question becomes why does one hospitalist order MRIs twice as often as another? The answer usually points to habits, training differences, or varying comfort with risk. These are factors we can actually address and improve.
Focusing on unwarranted variation does something remarkable. It gives executives and clinicians a shared vocabulary, transforming cost reduction from a tense negotiation into a joint mission to deliver better care. Standardized order sets, real-time feedback, peer benchmarking, and departmental performance reports can bring clinical and operational priorities into alignment. The quality of care doesn’t suffer. If anything, it improves.
