Length of stay (LOS) is a critical quality metric for hospitals that can affect reimbursement rates and margins, in both fee-for-service and value-based contracts. A higher average LOS is also associated with poorer health outcomes for patients, which is why hospitals and health systems are looking to decrease their LOS and exploring strategies to achieve that goal.
This was the major theme of a roundtable hosted by Sound Physicians at Becker’s Hospital Review 15th Annual Meeting. Roundtable participants included:
- Mihir Patel, MD, CEO, Sound Hospital Medicine
- Robin Rose, BSN, RN, chief operating officer and chief clinical officer, Gibson (Ill.) Area Hospital
- Neil Roy, MD, chief medical officer, Shady Grove Medical Center, Adventist HealthCare (Rockville, Md.)
- Thomas Spiegel, MD, vice president and chief quality officer, UChicago Medicine
Three key insights were:
- Decreasing LOS starts with everybody’s involvement and early planning. Not only should the clinical team providing care to the patient be focused on LOS, the quality team responsible for improving patient safety, operational efficiency and clinical effectiveness should also be involved. “If your quality team is not heavily involved in LOS, they ought to be,” Dr. Spiegel said.
Outpatient providers that serve as the patient’s first point of entry into the health system, such as family practices, must also be involved in efforts to reduce LOS. These providers’ knowledge of their patient’s medical history is crucial to planning the patient’s stay at the hospital and minimizing potential disruptions.
It is also critical to involve the patient and their caregivers — often family — who can inform the care team of circumstances, such as difficulties with transportation, that may delay the patient’s arrival for pre-education — a key element of reducing LOS. “One of the biggest initiatives we have started is pre-planning with families, which has decreased our admission on return,” Ms. Rose said.
Ideally, even post-acute facilities should be involved in a patient’s admission planning, so discharge nurses know who will be caring for a patient after discharge. “Partnering with local facilities allows us to make sure we can plan for discharge at the time of admission,” Dr. Roy said. “That makes a big difference and leads to a significant reduction in length of stay.”
- The dynamic between leadership and hospitalists is another key to improving LOS. Historically, healthcare organizations have had a clearly defined hierarchical relationship between C-suite leaders and hospitalists, but this dynamic is often unproductive when it comes to decreasing LOS. This is because hospitalists face multiple operational barriers to shortening a patient’s LOS, but those barriers can typically only be removed by the C-suite.
“We’ve shifted from a leadership team that leads from above to one where we exist to serve our hospitalist team and allow operations to occur effectively,” Dr. Roy said. Changing the culture to one where leaders empower hospitalists has been the key driver to reducing Shady Grove’s LOS rate from an average of 5.4 days to an average of 4.6 days.
“We’ve achieved that reduction with no addition of resources — only through restructuring our care management model and leader engagement, where everyone on the leadership team understands the barriers that every single patient has to being safely discharged,” Dr. Roy said.
Dr. Patel, who still practices hospitalist medicine alongside his executive role, concurred. “Hospitalists require a lot of support from hospital executives. Reducing LOS doesn’t work by hospitalists waving and saying, ‘I want to reduce LOS.'”
- Provider organizations’ goals around LOS are continuing to evolve. In the past two to three years, hospitals have started moving away from looking at total average LOS, which includes complex patients who require extended LOS, to geometric mean LOS (GMLOS), a CMS metric. “Most CFOs care about closing the gap between their hospital’s average LOS and the GMLOS,” Dr. Patel said.
Another evolving LOS trend is the understanding that different service lines and different patient populations have a different average LOS because of different care complexities. “To say that everyone’s LOS should be at X number simply isn’t real,” Dr. Spiegel said.
Yet another strategy that Sound Physicians proposes — and which many of its hospital partners have adopted — is shifting from Monday-to-Friday operations to seven-day, multi-disciplinary rounds and operations.
“On these rounds, you’re talking about patient throughput. You’re talking about how we can move patients along in their journey and prepare them for safe discharge while at the same time reducing LOS — so that’s the strategy,” Dr. Patel concluded.
