Consistence, insistence, and persistence’ are keys
Reducing patient length of stay (LOS) from nearly seven days to the regional average of 5.5 days usually takes two years, according to the Health Care Advisory Board in Washington, DC, a nationally recognized organization that provides best practices research and analysis to the health care industry.
But SSM St. Mary’s Health Center in St. Louis, a 582-bed community teaching hospital, did it in just two weeks. And while achieving a high level of patient satisfaction, it further reduced its LOS to five days 30 days later — ultimately reaching a record low of 4.7 days by the end of June 2002.
(SSM St. Mary’s Health Center is a member of SSM Health Care, which was named winner of the 2003 Malcolm Baldrige National Quality Award — the first ever presented to a health care organization.)
Three-part formula pays off
The keys to success for SSM were "consistence, insistence, and persistence," explains Mary Overstreet, RN, BSN, director of case management at SSM St. Mary’s.
"We communicate with you; we talk about what needs to happen with the patients in order to have effective quality care — which will automatically improve LOS," she explains.
"We do not go away. Every physician hears the same message, every day of the week. We are insistent, and we will have the literature and best practices to back up what we say. There are no sacred cows," Overstreet explains. "And this is not just a flavor-of-the-month change; this is our new process."
In addition, she and her staff promoted case management as a service to the physicians and their patients, as opposed to a punitive component of admitting.
"We want you to see us as a service the hospital is providing for you; because if you wanted your own case manager, it would cost you a fortune," Overstreet adds.
"We’ll figure out why your echo’ is not being done in a timely manner, track it down for you, and be your eyes and ears when you are not at the hospital," she says.
How it started
The process began April 17, 2002. The Medicare LOS for SSM St. Mary’s Health Center was 6.8 days for the month. The health center was struggling with inflated costs and poor patient flow.
Hospital president Ken Lukhard agreed with his supervisor, Mike Graue, executive vice president of network operations for SSM St. Louis, that changing the hospital culture was necessary to reduce LOS, and that it needed to be a CEO-driven effort.
Not wasting any time, Lukhard called on Overstreet to pull together a plan for getting at the root cause of the problem. He asked her to offer suggestions on how to improve; he gave her two hours to prepare a presentation.
Overstreet, with the help of Alka Kapoor, MD, a physician advisor to case management (CM), redesigned the CM model. They presented the new model to Lukhard that afternoon.
Afterward, Lukhard says he called an emergency meeting of the medical executive committee. He received its full support for the new model, and it was implemented the next day.
"We went through a lot of the CM literature out there," Overstreet recalls. "One of the sources we primarily used was by Kathleen Russell-Babin, Scaling the Outlier Brick Wall [The Center for Case Management; 1999]. It not only looks at what keeps patients in the hospital, but at your own processes that are not functioning properly, which can also keep them in longer," she says.
Internally, two teams were formed. The short-stay action team consisted of Lukhard, Kapoor, Overstreet, and others, including the social work team leader, Senior Care Coordination Center physician and director, case managers, and social workers, and a representative from rehabilitation.
The long-stay action team included representatives from the same groups plus medical staff representing various specialties (department medical directors).
Both teams met daily for an hour discussing LOS triggers within their respective LOS time frames. The short-stay team focused on cases with LOS of three to four days that appeared ready for discharge but had no documented discharge plan.
The long-stay team focused on patients with an LOS of more than 10 days. Once triggers or processes that caused an increase in LOS were identified, they were re-examined and addressed, Overstreet explains.
Many times, team members discovered an oversight that could be fixed easily. For instance, it was learned that some short-stay discharges were delayed pending a cardiologist’s reading of an echocardiogram. Once a daily schedule was established for a cardiologist to read echocardiograms of patients to be released, the LOS was reduced.
Identifying the triggers
"The first triggers we identified addressed patients in the hospital for more than 10 days," Overstreet recalls. "We would take each case and look at it and say, If you were medically ready to be discharged today, what are the impediments? If you are not medically ready, what can we communicate to your physician to make sure you get the best care possible?’"
Overstreet was put in charge of implementing the plan, with the full support of administration.
Additionally, the physicians were kept well informed and involved throughout the entire implementation process. "Our administration constantly involved the physicians. This was very important," she says.
She explains that Lukhard often visited the physicians’ lounge to ask how the medical center could improve operations. Plus, he sent mailings to physicians’ homes to keep them in the loop.
Overstreet says she is looking forward to a third physician survey to be conducted soon, having seen the physician approval rating increase from 54% to 80%.
The implementation of the new CM model involved breaking down a lot of barriers, she notes. "There were poor processes, and a lot of the culture needed to be changed. In particular, we had to address communication horizontally and vertically."
For example, she says, many staff were reluctant to approach physicians for fear of bothering them. When asked why, the reply often was something like, "No one ever has for 10 years."
"Our response was, Well, let’s start," Overstreet adds. "We took a fresh look at everything."
Results are retained
Not only were the initial results impressive, but St. Mary’s has kept those gains. They have kept their LOS low for more than a year. Other major benefits also emerged.
Emergency department diversion fell from more than 200 hours per month to fewer than 75 hours; the health center’s operating margin improved $1 million in 30 days; the readmission rate remained consistent; and most importantly, patient satisfaction — as well as physician satisfaction — did not decline.
From the point of implementation of the new CM model to significantly reducing LOS, Overstreet has kept a notebook of the plan, the activities, the progress, and the outcomes of their remarkable journey that illustrates the power of teamwork.
Could St. Mary’s success be modeled by other facilities? Overstreet says yes. "The first thing you need would be CEO support — it’s by far No. 1. Our hospital president became intimately involved; he had [CM] report directly to him and met with me twice a week."
In fact, people made jokes about her trying to teach him medicine, "But when he talked to the docs, he could sort of talk their language," she says.
The other key factor is consistency. "This cannot just be implemented for a short period of time," Overstreet insists.
"What we’re really promoting is quality — not just a decrease in length of stay to save money," she explains. "If you market an initiative as an effort to effectively improve quality, by its very nature, it will reduce LOS."
Need More Information?
For more information, contact:
• Mary Overstreet, RN, BSN, Director of Case Management, SSM St. Mary’s Health Center, St. Louis. Telephone: (314) 768-8145.