Do you want to solve your hospital’s length of stay (LOS) problems? Over the past 10 years, I’ve led and advised more than 100 small and large-scale projects that focused on improving clinical quality, cost and operational efficiency. I’ve found that the key to successful and sustainable improvement is using a disciplined step-by-step approach, which I’m sharing with you below.
Step 1: Diagnose the problem.
One of the most common mistakes I see is jumping to a solution before taking the time to understand what drives higher than expected LOS. Start with reviewing your hospital data to answer a few key questions:
- Is LOS impacted by admission/discharge month or day of the week?
- Is higher than expected LOS isolated to a service line, hospital unit or specific providers?
- Is it linked to a specific patient population based on age, payer, diagnosis, severity of illness or discharge disposition?
The answers will point you towards more targeted actions. For example, upon analyzing your length of stay data, you may discover that:
- LOS is highest for patients discharged on Mondays, a telltale sign that patients with complex post-acute needs are not being discharged on the weekends.
Action: Review weekend staffing and the workflow of your case management and hospitalist teams and make changes, if necessary.
- LOS is higher than expected for patients discharged from one of the medical units.
Action: Review and, if needed, redesign the current discharge process, including how anticipated discharges are identified, communicated and proactively managed by the care team.
- LOS is higher than expected for heart failure patients.
Action: Review the current heart failure management approach with your hospitalists and cardiologists and identify systemic barriers to timely discharges of heart failure patients (e.g., delays in scheduling or reading echocardiograms).
As we often find in healthcare, complex problems, like length of stay, have more than one underlying cause and may require more than one solution to see measurable impact.
Step 2: Assemble the team.
Start with identifying an executive sponsor – a senior executive whose role is to help engage stakeholders, secure resources and remove barriers. When assembling the rest of team, include representatives from all major stakeholder groups (e.g., hospitalists, nurses, case managers, physical therapists), but keep the team small enough to be effective. Look for people with the relevant knowledge and experience who are respected by their peers and can influence their opinions.
Step 3: Clearly outline your solution.
Let’s say you decided to focus on improving your process for proactive identification and management of anticipated discharges. Map out the process step by step, clearly defining WHO is accountable for completing each step.
Step 4: Engage front-line staff.
You may the come up with the best solution, but it will not be successful unless it is embraced by others. To engage your front-line staff (e.g., physicians, nurses, case managers), you must clearly communicate WHY the change is urgently needed for the benefit of patients and the hospital, and appeal to their minds, hearts and competitive nature.
For example, you may share your hospital, unit or hospitalist team LOS against national benchmarks to appeal to front-line staff minds. Often, data alone it is not enough to move people to action. You must appeal to their hearts by sharing stories of real patients whose lives were impacted by complications resulting from longer than medically necessary LOS. Leverage physicians’ competitive nature by sharing provider-specific severity-adjusted LOS or F/D ratio* as compared to their peers to spark a discussion.
Step 5. Evaluate impact.
Even before you implement a solution, set SMART (Specific, Measurable, Achievable, Relevant and Time-bound) goals. Ultimately, your solution’s success will be measured against its goals, so use your best thinking to define them. In addition, SMART goals will help to engage front-line staff and manage expectations of your executive team.
Here are two examples of project goals:
- Not SMART: Improve length of stay at Hospital A.
- SMART: Improve severity-adjusted length of stay on the Medical-Surgical Unit from 4 to 3.5 days within 6 months of project go-live.
As your implementation moves forward, do not let up or give up – continue to evaluate impact, remove barriers, refine your solution to get back on track if needed and constantly COMMUNICATE to share results and lessons learned.
Step 6. Sustain improvements.
Once you demonstrate the impact, consider including the metric (e.g., severity adjusted LOS) in your hospitalist team performance dashboard, regularly review and discuss performance to maintain engagement, and if needed, make improvements to get back on track.
Successful reduction of LOS requires a disciplined approach that is patient-centric, data-driven, team-based. By following these 6 steps, you will ensure that your solution is a win.
*Follow-up to Discharge Ratio = Sum of follow-up codes/Sum of discharge codes.
Want to improve length of stay at your hospital? Contact me if you have questions or want information about my services.