A quality improvement project to shorten lengths of stay and improve throughput from the ED at Saint Francis Medical Center in Hartford, CT, decreased the length of stay by more than half a day from November 2015 through May 2016.
The initiative was a collaboration between the case management department and nursing, with the help of an external consultant.
The revenue cycle area found that because of the resulting decrease in length of stay, they had to alter their contracting strategy and accelerate negotiation on any remaining per-diem contracts, says Beth A. Greig, RN, MSN, MBA, ACM, director of case management, healthcare value, and efficiency.
“While many of the insurance companies paid their hospital under a DRG, or case rate structure, there still were some insurance companies that paid the hospital on a per-diem structure. Decreasing length of stay under the per-diem payment structure was a concern and action was taken to minimize risk,” she adds.
“In the end, reducing length of stay does allow you to impact the revenue cycle in a variety of ways and the overall impact is based on the hospital strategy and market,” Greig says.
The initiative also reduced excess days by 5,869 from November through May. To determine the total excess day opportunities, the team calculated the excess days for each discharge by comparing the actual length of stay to a benchmark (the national Medicare geometric mean length of stay for that DRG). The excess days for each discharge were then added together to determine the baseline opportunity, Greig explains. “This calculation occurs on an ongoing basis to track progress,” she adds.
In late 2015, patient boarding in the ED for admitted patients was a concern and the hospital launched an initiative to decrease length of stay and improve patient throughput. Among the changes the team proposed were assigning hospitalists to a dedicated unit and improving care progression rounds by expanding the participants and assigning nursing a leadership role.
“We had always had rounds, but the role of nursing was not in the forefront. We made a decision as an organization that nursing lead the rounds, and we created a script for them to follow when they discuss each patient,” Greig says.
Participants in the rounds include hospitalists, case managers, clinical coordinators, social workers, physical therapists, and clinical documentation improvement specialists. The clinical documentation specialists attend the rounds to help determine the target length of stay for each patient, based on the Medicare geometric mean length of stay national benchmarks.
“Many members of the team didn’t realize that a target length of stay could be assigned to each patient. We incorporated it into our rounds so that the nurse may say, ‘this patient is on day 2 of a 4.2-day target length of stay.’ Now the team is aware of the target length of stay for an individual patient and can use the target as a guideline as they discuss the patient’s progression,” Greig says.
During rounds, the team discusses the patient’s clinical progress, quality metrics, barriers to discharge, and the target length of stay. The team set a goal of discharging as many patients as possible by noon.
Each patient is assigned a color-based status as the team discusses them. Patients in green status are expected to be discharged the next day. The team also identifies patients who can be discharged by noon. Yellow means the patient will be discharged in 24 to 48 hours. Patients whose stays are expected to exceed 48 hours are assigned a purple status.
The team places colored magnets on the white board on the unit, alerting the nurse from the evening shift to make patients in green status a priority and take care of all the discharge needs, such as completing patient education and developing a transportation plan with the patient and family.
“The entire team is engaged in working with the patient and family and lining up whatever is needed to make sure the patient can be discharged by noon. If the patient is going to a skilled nursing facility and the transportation is late, it’s a recipe for disaster. If patients are discharged to home at 6 p.m. and their pharmacy is closed, they can’t get their prescriptions,” says Caroline Segovia-Marquez, RN, BSN, MBA, ACM, RN manager for case management.
The project started on the medical units. The hospital assigned hospitalists to each of three major medical units so the patients would have care from the same team and could participate in rounds.
“In the past, we might have had a 20-bed medical unit and 13 providers making it difficult for case managers to succeed in coordinating care. When we localized the hospitalists, it had a dramatic impact,” Greig says. When the initiative started in December 2015, only 5% of the patients were discharged by noon. By June, the percentage was close to 20% for the hospital overall and some units exceeded 30% on a monthly basis.
“The length of stay dropped significantly in a short period of time, leading us to implement the process in every patient area. We have room for improvement, but we are making progress,” she adds.
The process has allowed the hospital to improve the boarding time in the ED for admitted patients, Greig says. “Back in October 2013, the average boarding time in the emergency department was more than three hours. By the end of May this year, it had dropped to an average of 140 minutes. While we had previously taken some action to reduce boarding time, with this initiative it has dropped to an average of 140 minutes as of the end of May 2016. By making sure patients are moved to their units quickly, we can begin patient care in a timely manner which contributes to reducing length of stay,” she says.
“This is one example of how case management and length of stay intersect with finance and reimbursement. We’re still working on ways to continue to be more efficient, but we’re closing the gap,” she adds.