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Critical Path Network
Interdisciplinary initiative reduces LOS by 2%
Staff learn it's not just case management's responsibility
Following a systemwide initiative, Catholic Healthcare Partners has reduced its average length of stay by 2%, potentially avoiding 18,000 hospital days in the multistate hospital system with headquarters in Cincinnati.
"We started our length of stay initiative in 2008 as we looked for opportunities to decrease waste in the system. The overall goal of the project is to reduce our observed length of stay to the expected length of stay, based on the Centers for Medicare & Medicaid Services [CMS] geometric mean length of stay," says Cathy Follmer, RN, BSN, MBA/HCM, CHCE, CRNI, corporate director of continuum of care services for Catholic Healthcare Partners.
As Follmer visited facilities throughout the health system in the beginning of the initiative, asking them to identify opportunities for improving length of stay, she heard the same thing at every facility — that it was a case management problem.
"We quickly realized that the first challenge would be changing that mindset. Case management plays a big role, but length of stay is a multifaceted problem," she says.
Length of stay affects the hospital's bottom line but also is a patient safety issue, Follmer points out.
"Patients are more likely to develop pressure ulcers if they stay in the hospital longer. They have a higher chance to develop infections and have more opportunities to fall," she adds.
The health system set up multidisciplinary tasks forces in each hospital to develop projects for improving length of stay, based on the organization of each hospital and the population it serves.
The length-of-stay task force at each hospital includes the chief executive officers or designee, chief operating officers, chief nursing officers, directors of case management, directors of quality, directors of patient safety, chief medical officers, and ancillary and post-acute services directors.
"This isn't a one-department project. It has to be hospitalwide. We looked at what processes are in place to improve patient-centered care and move patients safely through the system in a timely manner," Follmer says.
The hospitals used the Lean Six Sigma process as a foundation for efficiency, analyzing roadblocks in patient throughput and looking for ways to remove the obstacles for discharge.
Each hospital's task force looked at how the case management and nursing department worked, how the facilities were set up, and what processes were in place that could be done more efficiently to come up with individual projects for their particular facility.
"Everything that happens when patients come in the door until they are discharged affects the length of stay. For instance, if the correct information isn't collected at registration, that can hold up the discharge," Follmer explains.
One of the areas the task forces tackled was ancillary services. At some hospitals, the cardiac lab didn't do stress tests after noon and only in case of an emergency on weekends.
"That means that if a doctor decided on Thursday afternoon that a patient needs a stress test, he might not get it until Monday if the lab is booked on Friday," Follmer says.
The team looked at how many patients stayed over the weekend because they had a test on Monday that could have been done on Friday.
"We looked at the cost of keeping patients compared to having someone on call or opening the department on the weekends," Follmer says.
The team looked at what the cost savings might be if staffing was increased in some departments to handle tests and procedures and avoid keeping patients who otherwise were ready for discharge.
"We challenged the CFOs to look at return on investment. If it happened only a few times a year, it might not be worth it to add staff; but if patients were staying longer regularly, it might be financially viable," Follmer says.
Physicians told the team that many times, when they made rounds, the labs were not on the charts.
"Patients were being kept an extra day while waiting for laboratory and test results. This was an area of opportunity for many hospitals," Follmer recalls.
In some facilities, it was easy to find out what was holding up the lab results. In others, the team had to drill down to determine what was holding up the process and what needed to be put in place to expedite it.
"Sometimes it was changing the layout or upgrading the computer system to make the flow easier. At other facilities, labs weren't being drawn until 7 a.m. when they used to be drawn at 5:30 a.m.," Follmer says.
The team analyzed how many patients were admitted on Wednesday and Thursday but not discharged until Monday because the test results were not back when the physician made rounds on Friday. They used the information to determine if the ancillary departments needed to revise their procedures.
In some facilities, the primary care physicians routinely made rounds before the consulting physician came in to see the patient. As a result, even though the consulting physician said the patient could go home, the patient stayed until the next day, when the primary care physician wrote the discharge orders.
"We advised the medical staff to work with their physicians to put a method in place to get the patient discharged when the consulting physician says it's OK," Follmer says.
The teams looked at how tests and procedures were scheduled and how the process could be improved.
"If patients need an X-ray and a CT scan, the procedures can be scheduled back to back so the patient doesn't have to be shuttled back and forth between radiology and the room," Follmer says.
In many facilities, the physical therapy department is closed on Sunday and provides therapy to a limited number of patients on Saturday. This also caused holdups in discharge and problems for the patients, Follmer says.
"When a patient who is going to a skilled facility after discharge starts physical therapy on Thursday and doesn't receive it on the weekends, the three days of therapy that enables them to qualify for a skilled nursing stay goes out the window. We had to change the mindset of the physical therapists to solve this problem," she says.
Another initiative was to make sure that discharge planning starts on Day 1 in all facilities.
"In some facilities, the case managers did the initial review and went back to the chart to authorize the days, but they didn't look at the chart again until the physician wrote the order in the chart. This led to the case manager scrambling to try to set up the discharge. It was especially problematic if the patient was going to a long-term care facility and many times added two or more days to the length of stay while the case manager was getting the paperwork filled out and finding a facility," Follmer says.
The team challenged the case managers and nurses to work closer together and share information that helps with the discharge and to bring the entire multidisciplinary team into the loop.
"It's not a case management model or a nursing model but a care management model that involves collaboration among everyone in the multidisciplinary team," Follmer says.
For instance, the nursing aides spend a lot of time with patients and many times know a lot about the patient's home environment.
"They may know that a patient's bathroom is on a different floor from the bedroom or that the family is dysfunctional, information that can be important for early identification with choosing the appropriate level of care on discharge," says Follmer.
Levering technology, such as bed tracking, has been instrumental in many of the facilities as it alerts staff and physicians visually at a glance where the patient is, what the time is on the present length of stay, and who is pending discharge.
"Used correctly, technology can greatly enhance throughput. Choosing the right care model, utilizing available technology, and collaborating with all the players is key to reducing length of stay," Follmer says.
(For more information, contact: Cathy Follmer, RN, BSN, MBA/HCM, CHCE, CRNI, corporate director of continuum of care services for Catholic Healthcare Partners, email@example.com.)