Length of Stay: The Management Headache That Will Not Go Away

Redefinition of Core Roles and Streamlining Enabling Tools
Underlying the patient throughput management process are three critical and often overlooked infrastructure areas–Care Coordination, Social Work, and Nursing. These functions are the critical leverage points impacting overall institutional profitability. Typically, healthcare organizations have invested in efforts to address large cost areas in their supply chain or areas that drive direct revenue. It is less common to undertake a systematic analysis of these front-line care functions, especially Care Coordination and Social Work, even though performance in these areas has profound implications for the bottom line.

Some of the more important changes in these areas, which challenge base assumptions about traditional roles, include:

• Reversing the fragmentation of the role of the nurse, restoring clear accountability as the bedside care path manager
• Redefining the mandate of social workers, redefining what is often seen as a "patient advocate" role to a role which owns the hospital's objective to efficiently manage the discharge process, with competencies to aggressively negotiate with post-acute care providers
• Focusing care coordinators on care path analysis and adoption of best practices … rather than frittering away this skilled and expensive resource as a substitute nurse or an expeditor to cover for poor internal processes or unresponsive services

Engaging Physicians in Real Collaboration
Skyrocketing healthcare costs have provoked a new level of scrutiny from payers, patients, and the government. Demands for value in terms of improved health outcomes are increasing, and they are not being satisfied by the industry's traditional outcome metrics. This is straining what used to be a solid partnership between physicians and hospitals. Faced with the same economic squeeze, both parties have to work together to deliver better care and at lower cost.

Like it or not, tweaking the current care model isn't going to cut it. No one will get paid to fix infections acquired at the hospital or injuries due to falls. No one is going to choose a care provider based on a lower chance of operating on the wrong knee, or dying from surgery. Hospitals and physicians will be reimbursed based on the cost and quality outcomes patients achieve under their care.

This is the shared objective upon which hospitals and physicians must engage in dialogue and determine what they will change to achieve such an objective. Some hospitals are approaching their need to "engage physicians in dialogue" by hiring physicians and buying practices, in the unstated belief that once they are employees the hospital will have more control over their practice behavior. The real truth is that, if no one in the hospital has the accountability, skills, and power to negotiate with physicians over things they consider their sole prerogative, making them employees won't change anything.

The Financial Implications Deserve a Sense of Urgency
•Based on our patient throughput improvement work with large healthcare systems there are astonishing potential financial gains. Listed here are some of the typical savings that have been realized:

• Restructuring the role of the social worker resulted in significant staffing level implications. In one instance, 70% of their new patient assessments were redundant with the nurse's assessment and could be eliminated. This change alone allowed a 10% reduction in work activity which represented nine unnecessary positions at a loaded annual cost of $810,000.
• In redefining the care coordinator role, one client realized 50% of care coordinator activity was work that was a primary responsibility of other roles, particularly nurses and social workers. Keeping such work where it belonged allowed a staff reduction of ten care coordinator FTEs, which represented an annual savings of $900,000.
• Support service delays accounted for over 30,000 days of unnecessary LOS at one hospital. This hospital estimated the cost of a non-reimbursed patient variance day to be $2,000. Implementing a rapid turnaround of support service managerial accountability reduced LOS due to such delays by 25%, representing an annual savings of $15 million.
• At the same hospital discharge planning delays accounted for almost 35% of LOS variance. Providing social workers with improved tools and process and developing their negotiating competencies resulted in a 25% improvement in this area, representing an annual savings of $6.5 million.
• In another organization, physician lack of compliance with timely order entry, follow up, and discharge planning accounted for 10% of LOS variance, representing an annual cost of $7.5 million. Just the beginning of structured engagement and dialogue with physicians about outlier behaviors realized an immediate 10% reduction of this cost.

Assuming $2,500 as the opportunity cost for a non-reimbursed day, a hospital with 10,000 discharges foregoes over $6 million annually for every quarter day of average LOS variance. In a world of shrinking margins and almost inaccessible capital, how can the potential of patient throughput improvement not be a leading topic at every executive leadership meeting in your organization?