We are at a time of unprecedented change in healthcare. Hospitals are currently reeling from the aftermath of the COVID pandemic, desperately trying to regain their financial footing. Material inflation and labor cost have pushed the majority of US hospitals into negative financial margins. To survive, most hospitals are cutting costs, reducing length of stay (LOS) and trying to grow service lines with positive margins. Hospitals are attempting to balance increased census with the utilization of costly agency labor. The journey toward value in healthcare has accelerated, with many hospitals at risk of bankruptcy if they do not move quickly enough. To address the need to reduce LOS and hospital admissions, our health systems conducted a 6 weeks proof of concept. We implemented the following interventions (key results):
1) Reduce Variation among Physician Outliers: Managing length of stay is a challenge for every hospital. In the post-pandemic period, LOS has increased 20% according to Strata Decision Technology. We identified outlier physicians for LOS and created an individualized plan and coupled multidisciplinary rounding.
2) Enhanced Mobility: Implemented twice daily mobility and created the role of a patient experience liaison to assist nursing in ambulating patients to support discharge to the community
3) Increased enrollment in enhanced recovery after surgery (ERAS). ERAS has shown a great ability to achieve reductions in LOS and superior patient outcomes.
4) Hospital at home programs offer a unique balance of comfort and high quality care. Low acuity patients presenting to the emergency department (ED) can be safely treated in hospital at home programs rather than utilizing acute hospital infrastructure. They also are an excellent bridge to getting patients home earlier from the acute hospital setting when their underlying condition has improved, reducing acute care hospital length of stay.
5) We increased same or next day appointments in ED patients as alternative to some admissions. The ability to provide next day appointments with specialists, wound care, and pain management can often influence disposition in the ED, when complex or life threatening conditions are ruled out.
6) Utilizing Remote Patient Monitoring. We identified patients at high risk of readmission. With remote patient monitoring as an early warning system in the community, patients can have personalized intervention from trained professionals to provide medical advice or direct them to an appropriate site of care, rather than waiting for deterioration and utilizing emergency services.
7) Post-Acute Partnership: Partnerships with post-acute facilities and local emergency medical services are critical toward managing population health. By developing a strong relational network, post-acute patients can receive coordinated, higher quality care with superior communication among providers. In cases of advanced disease, having a clear understanding of patient goals of care and transport to the hospital is key to keeping patients and families satisfied with care, and making sure care is a value to the patient.
8) Post Discharge Relationships: A comprehensive primary care network with active, engaged management ensures patients have the best chance to live higher quality lives outside of hospital walls. Post discharge, pharmacists can help manage chronic conditions and ensure patients have received all medications on the medical reconciliation at time of discharge and beyond.
The system and local leader for each of these efforts met weekly to coordinate effort, monitor performance, and plan how to improve. The observed/expected LOS fell from 112% to 98% after intervention with a similar CMI. Twice daily mobility increased from 20% to 70%, ERAS compliance increased from 60% to 80%, hospital at home referrals increased from zero patients to 2-3 per week. ED next day visits to a specialist increased from 2 to 7 per day.
While many of these initiatives have had some success in isolation, the synthesis of all of these programs was instrumental in LOS reduction and census management at our facility. System stakeholders engaged with entity leaders using partnership and education, moving from “command and control,” to “unleash and inspire.” When hospitals are forced to operate above staffed capacity, throughput worsens. With the current labor constraints, improved throughput mean less ED boarding, reducing patient harm. Better management of throughput allows for safer staffing ratios, excellence in quality, and superior patient experience- allowing patients to get the care they deserve.
Authors:
James Hill MD, MBA, CPE, FASA, FACHE
Chief Operating Officer, University Hospitals Parma Medical Center
Christopher Dussel MD, MBA, CPE, FACEP, FACHE
Chief Medical Officer, University Hospitals Parma Medical Center
Brian Monter MSN, RN, MBA
Chief Operating Officer, University Hospitals Health System West Market
Kimberly Togliatti-Trickett, MD, MBA
Chief Medical Officer, University Hospitals Health System West Market and Transitions of Care
Peter Pronovost MD, PhD, FCCM
Chief Quality and Clinical Transformation Officer, University Hospitals Health System