Interdepartmental team earns leader quality award
Interdepartmental team earns leader quality award
Average length of stay is reduced significantly
An interdepartmental quality improvement team at Norwalk (CN) Hospital has developed and implemented strategies that led to a reduction in the average length of stay for all patients from 5.54 days in 2007 to 4.1 days in 2009. The figure for Medicaid patients, which had been as high as 7 days, is down to 4.8 days.
In recognition of these accomplishments Claire Davis, RN, MHA, CPHQ, FNAHQ, vice president of quality, was presented the Luc R. Pelletier Healthcare Quality Award for Improving Organizational Performance given by the National Association for Healthcare Quality.
"The most important step we took was that we determined that length of stay [LOS] reduction for the hospital should be a strategic initiative, and that it required a strategic team," she recalls. "The initiative was chosen first."
Senior leadership, she continues, recognized that the hospital was starting with a very strong base in terms of patient quality and safety. "We had a record of which we could be proud, but our average length of stay was one of the five longest in the state; we felt this was a significant opportunity for improvement," says Davis.
Another important decision, Davis notes, is that even though LOS impacts finance and efficiency, it was determined that the initiative should reside within the quality sector. "Leadership felt that clinicians would appreciate the fact that LOS is first and foremost a medical decision, and that it's best for the patient to be at the appropriate level of medical care," she explains. "If you talked to nurses and doctors and said you wanted LOS down because it would save money, they'd get a bad taste in their mouths and ask about the patients."
The fact is, she notes, when people are kept in the hospital their opportunity for not being healthy is greater. "Older people face changes in mentation, and they do not move as much so they are more prone to skin breakdown and circulation issues," Davis observes. "Most of us recover faster functionally in our own safe environment with nutrition and lifestyle patterns we are used to."
Finally, she observes, InterQual and Medicaid "tell us there's no reason to be in the hospital unless you meet acute care standards, and we knew this was not always the case."
Selecting strategies for improvement
In order to determine strategies for improvement, "sponsors" were placed in the interdepartmental team at the senior leadership level. "I led the team for quality, and we put the CFO as a sponsor, too, to show the relationship between quality and finance," says Davis.
They then appointed two team leaders — the director of case management and the medical director of the hospitalist program, who was also an internist and medical vice president of integration. "These are the two major groups that work on LOS every day — the hospitalists treat 60% or more of our patients," Davis explains.
Then Davis and the two team leaders sat down and looked at the data and the history and used root cause analysis and Pareto charts to identify the largest trends, conducting interviews in areas where they saw numbers that were "out of whack." "We spoke with key clinical and non-clinical people and asked what barriers they had experienced, and identified eight areas we felt we needed to approach," says Davis.
Out of those eight, the top four priorities were determined, and targeted for 2008.
The first issue addressed was the case management department itself. "Hospital senior leadership had not given them the resources they needed — they did not have Midas software, they did not have integrated InterQual material (which they do now) and they did not have enough staffing," says Davis. "We felt it was critical to put two case managers in the ED to help identify inappropriate admissions before they even came in the door, because when a social admission gets through the door they are very hard to move out."
Physician barriers also were addressed. "We developed senior medical leaders through their own customary chain of command to back up and champion the case managers on their authority," says Davis. "It was their responsibility to give the case managers access to the doctors every single day."
Multidisciplinary rounds, or MDRs, were instituted. "The hospitalists and hospitalist residency program really helped us," says Davis. The daily rounds included dieticians, nurses, and case managers, and met for over an hour and one half. "Teams of doctors would come in four at a time and review every patient under their service," Davis notes.
If patients were not being discharged, the barriers were explored. "If they still needed an MRI, radiology was called," says Davis. "If a patient was not clinically acute, the decision was made to discharge. We really identified what was stopping us from discharge and then got it in motion — forcing efficiency."
The final first-year priority involved working with the ED to reiterate criteria for acute admission and placing the case managers in the ED. "A) they acted as consultants, and B) they have better resources to find safe places to discharge people to," Davis explains.
New programs in '09
This year, one of the areas of focus has been rehabilitation. "We own a unit here at the hospital, and we found that our patients with rehab DRGs had longer lengths of stay before being transferred," says Davis. "The doctors let them sit on the acute side, thinking they were doing the right thing, but it is not a transfer to move them to our rehab facility. It is a discharge, and then an admit. We were seeing unnecessary two-day delays."
In surgery, daily rounds were instituted to help bring down LOS. The nursing role in LOS throughout the hospital was also addressed by working on ambulation and nutrition and bowel routine. "We explored what they could do to help ensure their patients would not lose mobility," Davis notes.
Finally, a culture of change among all physicians is being sought. "We have to go out to private physicians in the community and change the way they look at LOS," says Davis. "Our physician leader will also be going out to departments and sections and providing actual clinical data on LOS and its relationship to cost and quality, how their department has looked over time, how it looks when benchmarked against other facilities, and how their individual data compares with that of their peers. He will also let them know the resources we have to help remove barriers for them."
Gaining support not a problem
While staff buy-in can be a problem with such ambitious initiatives, Davis says that in this case it was not. "Before leadership made this a strategy and supported the grassroots, the staff frustration was that they knew the right things to be done but they did not have the resources, the authority, the equipment, or the people," she shares. "It wasn't rocket science because they all knew what was needed."
One of the other keys to success, she continues, was the strategic approach. "When you do not approach this as a strategy, you do not have the whole hospital working on it," she explains.
Finally, she says, the team used a no-nonsense, business-like, rapid-cycle approach to their meetings. "We assigned a limited number of people to the monthly meetings and said that if they had an hour to sit, great, but if they were busy we'd give them a five-minute slot to share their baseline data, discuss what they did to improve, what barriers remained, and how we could help." If the presenter said they had not worked on the project for the past month "we did not accept their presentation," Davis says.
As the meetings unfolded, "once they really started catching on, clinicians liked to sit and hear other clinicians present when they could," says Davis. "When you bring forth a CQI story it holds peoples' attention."
[For more information, contact:
Claire Davis, RN, MHA, CPHQ, FNAHQ, Vice President of Quality, Norwalk Hospital, Norwalk, CT. Phone: (203) 852-2212.
An interdepartmental quality improvement team at Norwalk (CN) Hospital has developed and implemented strategies that led to a reduction in the average length of stay for all patients from 5.54 days in 2007 to 4.1 days in 2009.Subscribe Now for Access
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