Critical Path Network

Six Sigma project slashes LOS for SNF discharges

Initiative targets ambulation, early assessment, discharge planning

The length of stay for patients being discharged to skilled nursing facilities from St. Joseph's Hospital progressive ventilator care unit dropped by 7.5 days (a 47% reduction) following a Six Sigma pilot project that focused on better ambulation of patients, earlier screening for potential skilled nursing admissions, and timely discharge.

"We discharge a lot of patients to skilled nursing facilities. We felt that their length of stay was longer than it should be and that there were opportunities to coordinate the care of these patients in a more efficient and effective way, while improving the length of stay and the outcomes," says Elizabeth Galvin, RN, MBA, manager of clinical resource management for the Tampa, FL, hospital.

St. Joseph's Hospital is part of BayCare Health System, which includes nine not-for-profit hospitals in the Tampa Bay area.

In addition to the overall improvement in length of stay, the six-month project achieved the following outcomes in areas where the team focused:

  • Functional status assessed upon admission increased by 28%. Activity levels ordered upon admission for a patient went up 131%. Ambulation one to two times a day for eligible patients rose 71%.
  • The number of discharge planning assessments completed within 24 hours of admission increased by 43%. The percentage of discharge orders executed on the same day they were written rose by 25%.

The project was designed and implemented by a multidisciplinary team that included representatives from case management, social work, nursing, medical assistance, finance, medical records, and pastoral care, according to Tanya Siddiqui, Six Sigma Black Belt, who led the team.

The Six Sigma team chose 5 North, a step-down intensive care or progressive care unit for the pilot project. The unit has multiple patients on ventilators and with tracheostomies, and discharges a large percentage of its population to post-acute facilities, Galvin says.

"We chose this unit because the population has very complex needs and a high length of stay. The quality of nursing care and leadership was another factor in our choice. We knew we could count on the staff for the extra effort involved in any pilot project," Galvin says.

Patients in the progressive care unit include trauma patients, those with severe chronic illnesses, cardiac patients, or postoperative patients who need to remain on life support. They require a lot of complex care but are more stable that patients in the intensive care unit, says Joanne Mayers, RN, nurse manager of the unit.

"We face some unique challenges in our unit because of the clinical complexity of our patients, along with the fact that many of them are unfunded. We have a difficult time placing them because there are limited options in the Tampa area for discharging patients who are on a ventilator and who do not have funding," she says.

The team began the process in December 2006 by determining what the problem was and identifying opportunities for improvement.

They reviewed charts for a one-year period to determine what roadblocks prevented patients from being discharged to a skilled nursing facility in a timely manner.

"We all had feelings about why length of stay was longer than it should be and what the opportunities were. Part of the process was to determine what the issues were using statistics not anecdotal information," Galvin says.

The team identified three main areas of focus: ambulation of patients, early identification of potential skilled nursing and rehab discharges, and executing the discharge orders the same day they were written.

The team then drilled down to determine specific steps that could be taken to make improvements in each of the key areas.

'Ready, Sit, Go!'

They developed a pilot called "Ready, Sit, Go!" to alert the staff to the Six Sigma Project and its goals.

"We conducted education for all the nurses on the unit. Case managers and social workers were also involved in getting the word out that the project was going to begin," Siddiqui says.

During its chart review, the team determined that some patients, particularly those who came to the unit from intensive care, were becoming debilitated because of extended stays in bed.

"Many of the patients on the unit don't necessarily have to stay in bed. This was a big change in mindset for the physicians, nursing staff, and case managers," Mayers says.

Among the goals the team set were having all patients assessed for functional status as soon as they were admitted to the unit and making sure that everyone on the unit has activity-level orders within 24 hours.

If the physician doesn't order bed rest, the goal is to have the patients up in a chair a minimum of once a day and to ambulate them if they are able.

"Physical therapy did an inservice for staff on mobilization to teach them how to get those patients moving. Many of the patients on the unit could be ambulated by a nurse, instead of a physical therapist," Mayers says.

In addition to shortening the length of stay for patients going to skilled nursing facilities, the increased attention to ambulation also resulted in a decrease in the number of patients who needed to go to an extended care facility, Siddiqui says.

"Ambulating the patients more during their stay in a progressive care unit helps improve their conditions and allows them to go home healthier. This project has improved patient satisfaction and decreased the cost of health care. Patients are going home healthier with improved outcomes and their insurers aren't being billed for skilled nursing care," Siddiqui says.

In addition, because of the positive outcomes from the Six Sigma project, the nursing unit purchased a second special power chair that folds down to allow nurses to slide patients out of the bed, rather than lifting them.

"Like many hospitals, we have a no-lift policy because of increasingly morbidly obese patients. It's a challenge to get them up when they are obese and on a ventilator. Getting the new equipment makes it easier," Mayers says.

Like any new initiative, the idea of increased ambulation of patients initially met with resistance.

"The nurses completely support the process now that they have seen dramatic improvements from the ambulation. It's made the atmosphere on the unit more progressive and positive," Mayers says.

The project's goals called for a proactive approach to identifying patients who were likely to be discharged to a skilled nursing facility in order to facilitate getting the patients transferred once the order is written.

The nurses began screening patients upon admission or transfer to identify good candidates for a skilled nursing facility and alerting the case manager and social worker.

The social workers concentrated on getting the discharge planning assessment completed within 24 hours of admission to the unit.

"The social workers look at all of the aspects of the discharge from payer status and medical diagnosis to the support system at home early in the stay. They start talking to the patient and family about skilled nursing care early in the stay, getting them accustomed to the fact that the patient may not be discharged to home," Mayers says.

The team added a section to the discharge planning form that includes information about patients likely to be discharged to skilled nursing facilities. The case managers and social workers have a place to note information such as family concerns, copays and other insurance issues, potential outcomes, and deterrents to admission.

"We identified key family issues involving transferring patients to extended care facilities and tried to address them and to improve communication with the family in regards to these issues," Galvin says.

For instance, the terms "nursing home" or "skilled nursing facility" tend to have a negative connotation with family members. Instead, staff tell the family that the patient needs to go to a facility for rehabilitation.

The team determined that not all patients were discharged to a skilled nursing facility on the day their discharge orders were written, many times because the paperwork wasn't in order or medication reconciliation had not been completed.

In some cases, the physician fails to sign all the required forms for discharge; in other cases, the facility the patient wanted may not be available. Sometimes, transfers are held up by the patient's special needs or by requirements from a managed care organization.

"We are working to get the paperwork complete and everybody on board," Mayers says.

The interdisciplinary team on 5 North has a weekly length of stay meeting attended by their physician advisor and Galvin, during which the team looks at long-stay patients and obstacles to discharge.

In addition, 5 North holds weekly interdisciplinary rounds to look at discharge issues with input from the rehab team on how the patient is improving physically.

During the daily huddle, the case manager, social worker, and charge nurse discuss any obstacles to discharging patients.

The nurses write the patient goals for each day on a dry-erase board placed in the patient rooms where it can be seen by the patient and family.

"It helps us communicate goals from shift to shift and keeps the patient and family aware of the goals," Mayers says.

Following the success of the Six Sigma project, the team is continuing to look for other opportunities to improve length of stay. The hospital is forming partnerships with extended care facilities and developing tools, such as virtual tours of facilities, to help the patient and family make informed decisions, Siddiqui says.

"We are involving the extended care facilities in this initiative, making sure they get a liaison on site to talk to the patient and family about issues and questions they may have. In addition, representatives from hospice care and palliative care are part of the rounds on the nursing floor and the unit," she adds.

The clinical resource management department at St. Joseph's is responsible for coordinating the care of adults in the main hospital. The average daily census for this group of patients is 425.

The department includes RN case managers and social workers who are unit-based.

The case managers have primary responsibility for utilization review, tracking and reporting avoidable days, managing observation patients who are placed throughout the hospital, tracking and reporting evidence-based measures, and driving the length of stay for their units.

The social workers have primary responsibility for completing the initial discharge planning assessments and coordinating the discharge planning process to alternative level of care facilities. They address patient psychosocial needs and arrange other discharge services such as transportation, outpatient therapy, unfunded patient prescriptions, and community services.

(For more information, contact Elizabeth Galvin, RN, MBA, manager of clinical resource management for St Joseph's Hospital, e-mail: