Initiative emphasizes interdisciplinary collaboration

Systemwide staff can earn bonuses if goals are met

As the result of an initiative in which the entire hospital staff collaborate to improve length of stay, Spartanburg (SC) Regional Healthcare System's average severity-adjusted length of stay has dropped from an average of 5.40 days in 2007 to an average of 5.18 days so far in 2008.

In May, the severity-adjusted length of stay at the 588-bed tertiary care hospital was 4.85 days.

The hospital system includes a heart center, a cancer center, a long-term acute care hospital (LTACH), a 25-bed skilled nursing facility, and a regional physician network. The system is opening a second hospital 30 miles away in October.

"Our health care system's strategic goals for the past two years have included a length of stay goal. Length of stay was already a focus of case management, so we have worked very hard to continue to improve length of stay beyond just what case management can impact alone," says Angie Roberson, RN, BSN, CPUM, director of case management for Spartanburg Regional.

Among the length of stay initiatives are morning huddles each day between the case management and nursing staff, weekly rounds, and a length of stay meeting during which nursing and case managers discuss long-stay patients.

In addition, a series of Lean Six Sigma projects targeted improving patient throughput on individual units.

Roberson attributes the success of the initiative to developing a close relationship between nursing and case management, and creating a culture change within the hospital.

"Everybody in the hospital had a hand in our success. By working together we have been able to accomplish far more than we could have if we were working individually. We're seeing culture change, and that's why it's taken two years for this to happen. It's all about changing the culture and not just telling people they have to do something," she says.

The initiative's beginnings

The initiative started two years ago when the hospital system created systemwide goals and tied them to its regional gainsharing program that began in 2001. If the hospital system meets certain goals set by the board, employees are eligible for a bonus of up to 5% of their salary.

Once the hospital system meets its financial indicators, the whole system has to meet the gainsharing goals for employees to qualify for bonuses.

"The whole goal of the gainsharing program is to increase awareness of the financial side and for employees to feel like they have a vested interest in the financial stability of the hospital," Roberson says.

In the first years of the gainsharing program, goals included successful scores on The Joint Commission survey or meeting patient satisfaction goals.

Now the initiative's goals include the severity-adjusted length of stay, the mortality index, and patient safety goals. The goals are publicized every month to employees through the health system intranet and are discussed at staff meetings.

The hospital always has had a length-of-stay goal, but it was not until the goal was tied to the gainshare bonus that the entire hospital staff understood that everyone in the hospital, not just the case managers, plays a role in reducing length of stay, Roberson says.

"Essentially, in the beginning, I was the cheerleader for length of stay. I spent a lot of time explaining what the severity-adjusted length of stay means, what is included, how it is benchmarked, and how everybody from the clinical staff to the ancillary departments to transportation and housekeeping have a hand in it," she says.

One of Roberson's initial goals was to help the staff understand that reducing length of stay is good for the patients as well as for the hospital.

"A lot of people think reducing length of stay is only about the hospital bottom line, but the quicker we can get these people in and out, the better off they are. I had to educate the staff that length of stay isn't about kicking people out the door. It's about ensuring that patients get appropriate care at the appropriate time and then move to a more appropriate level of care," she says.

In June 2007, the case management department began an initiative to develop a working relationship between the case managers and the nursing staff so the two disciplines would work as a team, rather than individually.

The effort began with a kickoff celebration in the hospital auditorium, complete with music and a big road map on the wall, signifying that the disciplines were embarking on a journey together.

The celebration was attended by the nursing director, the nurse manager, the clinical nurse educators on the nursing unit, and the charge nurses on each unit if they could get away.

The clinical nurse educators work in coordination with the nurse managers on the unit. They are responsible for unit education for staff and are involved in performance improvement initiatives. They dress in uniform and can step in and do patient care when needed.

The upbeat occasion included refreshments, games, and a chance for the disciplines to get to know each other.

The vice president for case management and the vice president for nursing kicked off the meeting.

"It was critical to demonstrate that people on the vice president level believed in what we were doing and supported it," she says.

Roberson discussed how the disciplines could work together to share information and improve patient care.

"We shared with nursing what case management had been doing and how we needed to be friends and partners with them. We told them we were being challenged as a system to meet goals that we couldn't accomplish if we worked independently," Roberson says.

One initiative was for every unit to have an early morning, 15-minute huddle between nursing and case management.

"This isn't easy to accomplish, because they see it as a major interruption in their work day. But once they got it going, they realized what a benefit it is," she says.

Roberson took the opportunity to discuss the new requirements for issuing the Important Message from Medicare that was about to be put into effect.

She asked the nurses to work with the case managers to identify as soon as possible when patients are close to being discharged and to put a pink sticker on the front of the chart identifying the discharge date.

"The meeting also was an opportunity to tout the benefits of the multidisciplinary rounds and of having both nursing, case management, and the other disciplines collaborate on what the patient needs," she says.

During the rounds, the team looks at issues that could affect a patient's readiness to be discharged, such as if they are eating, eliminating, if they have wounds, need IV medications, or they have support at home. They look at whether the patient's needs could be taken care of at home or in a skilled nursing facility, she says.

"The meeting marked the beginning of building the relationship to work collaboratively and the expectation of sharing data," she says.

(For more information, contact: Angie Roberson, RN, BSN, CPUM, director of case management for Spartanburg Regional, e-mail: