Rethinking LOS: Focus on process improvement and the days will drop
It's not the solution, but how you get there that matters
It's one of the thorniest and most emotional issues in health care: How long should patients be allowed to stay in the hospital following an illness or surgical procedure? With hospitals and managed care companies battling in Maryland and elsewhere over the interpretation of length of stay (LOS) guidelines, and Congress once again threatening to crack down on HMOs, some experts worry that we could soon face another push to legislate the medical management of patients. Others, however, worry that without such legislation, hospitals will be forced to cut LOS so close to the bone that patient care could be threatened while costs are merely shifted to elsewhere in the continuum.
Karen Zander, RN, MS, CS, FAAN, principal and co-owner of the Center for Case Management in South Natick, MA, says she's concerned by the fact that some quality professionals think cutting LOS is synonymous with cutting costs and increasing efficiency. She says the emphasis on solutions and improving quantifiable outcomes has obscured the need to improve the processes that create positive outcomes. (See related story, Hospital Case Management, April 1998, p. 65.)
"If your process is in place and correct for a given patient, your length of stay isn't going to be an issue," says Paula S. Swain, RN, MSN, CPHQ, president of Paula Swain Seminars and Quality Consulting in St. Petersburg, FL. "I mean, if the patient needs a certain level of service and you have been very efficient in getting the testing done, getting the antibiotic in place, and that sort of thing, then that's how long it takes for that patient."
Swain adds that simply lowering LOS is a "quick fix," and focusing too much on LOS numbers can give case managers misleading ideas about the success of a pathway. For example, if patients have a "path pause" or go off the pathway, average LOS for the procedure is likely to increase, leading some to conclude that the pathway isn't working. In fact, the problem may be that "the people who are integrated in the path aren't cueing off each other," Swain says.
"We've been slow at emphasizing the variances in the pathways that point us to becoming more efficient," Swain says. "If you and everyone else who works in the process understands how the process works, then you're going to save money, save energy, and be more efficient and effective."
When a team thoroughly understands the plan of care for a population of patients, team members are taken by surprise less often and are better able to manage patients, whether or not those patients are on a pathway, Swain says. "They've got a heads-up that, gee, after the third day, we're always going to have a high propensity for a certain problem to happen," she says. "And in that situation, if everyone is knowledgeable about that, they're much more efficient at doing their assessment and putting the patient on the right track in the first place."
Swain also notes that for many procedures, the bulk of the costs are incurred in the first few days, with additional days not necessarily adding much expense. In those situations, a lower LOS may look good on paper but adds little to the hospital's bottom line.
And if your hospital is part of an integrated delivery system, cutting LOS irresponsibly could have a negative impact on the bottom line, not to mention resulting in patient outcomes that are less than stellar. In some cases, for instance, fewer days in the hospital simply means more days in outpatient rehabilitation, or home care, or even return visits to the hospital.
Such cost shifting, however, isn't always a bad thing - at least according to Milliman & Robertson (M&R), the Seattle-based actuarial firm that has ignited controversy with its stringent LOS guidelines. "The goal of medical management really is to align the person's medical acuity with the proper level of care," says Gary Brace, FSA, a consulting actuary with M&R in Atlanta. "If a person is medically stable enough to be transferred from, say, an inpatient to a subacute setting or to some type of postacute setting, then presumably there's less intense nursing equipment needed, so the costs are going to be slightly reduced. So, yes, there's a shifting to different levels of care, but it's not like [the patients] are being discharged back into the home without any kind of follow-up. There's a transitioning or a stepping down as the acuity starts to stabilize."
M&R remains sensitive about its image and what it considers an unfair portrayal of it as a company that values cost containment more than effective patient care. That image has arisen largely because of the way some managed care organizations have interpreted the company's guidelines. The Baltimore-based Maryland Hospital Association, for example, has charged that several insurers in the state, including the local Blues, have regarded the guidelines as absolute standards, denying days beyond what M&R recommends for a given procedure. (See "Slow pay and claims denials: Welcome to the world of managed care," HCM, June 1998, p. 109.)
Brace says that's an "incorrect interpretation" of the guidelines. "The guidelines are just that," he says. "They're guidelines that are applied to an average uncomplicated diagnosis. If there are comorbidities, then there needs to be a clinical judgement applied, not necessarily hard-and-fast adherence to the guidelines."
Brace adds that M&R actuaries themselves don't blindly apply the LOS recommendations contained in the guidelines when conducting chart reviews. "When we assess network efficiency, we'll use the guidelines as benchmarks, but we'll take them with a grain of salt if we recognize through the chart review process that there are comorbidities. If the length of stay says they should be discharged in three days but we recognize that there were certain additional diagnoses that necessitated a longer length of stay, then we're not going to say an extra day or two was inappropriate."
For more information, contact the following:
Gary Brace, FSA, consulting actuary, Milliman & Robertson, 3343 Peachtree Rd., Suite 1250, Atlanta, GA 30326. Telephone: (404) 237-7060.
Paula S. Swain, RN, MSN, CPHQ, president, Paula Swain Seminars, Inc., and Quality Consulting, 5075 54th Way, North St. Petersburg, FL 33709. Telephone: (813) 526-6605.