Studying a range of data sets at your hospital may reveal opportunities to improve outcomes and cut costs, says Nancy Lakier, RN, BSN, MBA, CEO and managing principal of Novia Strategies, a consulting company based in Poway, CA. The outliers and unusual numbers will point you toward issues that need more investigation, she says.
“Why is one physician having fewer readmissions than others? Why is one service line having fewer readmissions?” she says. “There are all sorts of quality indicators to look at that can guide you toward what you can do to improve quality, not just in the hospital but also post-discharge.”
In working with data sets on congestive heart failure with myocardial infarction recently, Lakier saw that one physician at the hospital had an average length of stay three days higher than other physicians, with a commensurate increase in costs. When she drilled down into the reasons for the variance in length of stay for that physician and other outlier physicians, she saw that one factor was the pharmaceuticals prescribed by those physicians.
“They were dramatically different. The high-cost physicians used drugs that varied significantly from the others,” she says. “That doesn’t always mean those drugs are inappropriate, but sometimes it’s just a matter of asking the question. The physician might respond that he didn’t realize his choice was so much different from everyone else’s and he could use the other drug and get the same results.”
It also is common for nurses and physician assistants to order certain drugs, lab tests, or therapies because they think that’s what the physician wants. They’re mistaken, but the physician doesn’t object, Lakier says.
At one hospital, Lakier determined every patient received a physical therapy risk assessment for falls prior to discharge. When she asked why the risk assessment couldn’t be performed by a nurse instead of physical therapy in most cases, she was told that about 10 years earlier there had been a bad patient outcome blamed on a lack of adequate fall assessment.
“Ten years later, they still had that assessment in place and it was adding a half a day to the length of stay for every patient in the hospital,” Lakier says. “Plus, they had increased their physical therapy staff way beyond what any other hospital used. The chief nursing officer said there was no reason they couldn’t do most of the assessments, but no one had ever questioned the policy.”
Once that policy was rescinded with the approval of the physicians, the hospital’s length of stay decreased, and so did overtime costs for the physical therapy department.
In another example, Lakier studied data sets and saw that a bariatric surgeon was performing 70 appendectomies per year, but the hospital was using a $381 special bariatric tray insert rather than a standard and far less expensive appendectomy tray. The surgeon’s staff most likely provided the more expensive tray because the doctor previously requested it, or it might have been specified on his preference card, Lakier says. Either way, the costly tray was not necessary for an appendectomy.
In other cases, the data may show that one physician keeps patients in the ICU longer than others. A little investigation may reveal that, for whatever reason, the surgeon doesn’t trust the care provided on the med-surg floor.
“Sometimes you have to fix operational problems before you can address the clinical variance. You might have to bring up the quality of the med-surg staff before your surgeon will be willing to change his ways,” Lakier says. “Sometimes patients are staying in the hospital because they can’t get in to the OR. So you have to find out what’s going on in the OR and what you can improve in the perioperative area to get those patients in faster. ORs often are at max capacity, but that might be because their operations aren’t so smooth.”
