A Closer Look at Length of Stay
In November, BWH rolled out its new Strategic Plan designed to guide the hospital through the challenges of the next decade. Essential to the organization’s continued focus and success, the plan provides a structural roadmap with specific goals and objectives.
One of the key areas of focus, involving a wide variety of disciplines, is length of stay (LOS). The goal over the next three years is to incrementally reduce LOS at BWH by .2 days each year, down from the current level of approximately 5.5 days.
In addition to a Length of Stay Task Force to oversee and drive the plan to reduce LOS, representatives from each of the hospital departments are working hard to implement and communicate the initiatives associated with the plan.
Under a new care coordination model to be implemented in the months ahead, every patient will have a care coordinator to monitor and facilitate his or her care on a daily basis. No longer will care coordinators only be involved with complex patient cases. In order to make this happen, aggressive recruitment of additional coordinators has been under way.
When all nurse care coordinators are on staff, there will be one care coordinator for every 20 to 25 patients, which is a marked improvement from the current one to 35 ratio. In addition to being intensely involved in patients’ daily care, coordinators will also participate in pre-admission telephone calls for elective admissions and in post-discharge follow-up phone calls occurring 24 to 48 hours after discharge.
To continually monitor its progress and areas of opportunity related to length of stay, BWH uses Managed Care Appropriateness Protocol (MCAP), an industry accepted medical management criteria set to identify the medical appropriateness of each of the days of a patient’s hospital stay. The criteria are broken down to six categories of non-qualified hospital days, which include physician related, alternate care availability, social factors, administrative issues, facility related (system issues), and extenuating circumstances. By monitoring the MCAP data one week out of each month, the Length of Stay Task Force receives a snapshot of the status of each of the factors associated with LOS.
Much energy has been focused on more efficiently discharging inpatients to post acute care facilities. From rehabilitation facilities to skilled nursing facilities, discharges to these institutions must be timely and appropriate for BWH patients. The improved care coordination model will help in expediting that process.
Another area of opportunity to decrease LOS rests in clinical care pathways. According to Andy Whittemore, MD, chief medical officer, many clinical services and care improvement teams have been working with physicians, nursing staff, and other members of the care team to update current critical pathways and create new ones when needed.
A dedicated oversight group is also hard at work designing a more user-friendly format for all care pathways, including one that will allow all disciplines to document patient progress, achievement of milestones, and variances from the intended plan in the same place.
An extension in a patient’s LOS can also be caused by administrative factors or system issues. Teams are working to alleviate the delays sometimes found in scheduling and reporting laboratory and imaging tests, both of which can significantly prolong a patient’s stay.
The underlying theme to the improvement of all factors affecting LOS is communication. Efforts are underway to ensure the entire patient care team is informed of the discharge plan in addition to communicating the intended discharge time to the family and patient.
According to Michael Gustafson, MD, director of performance measurement and analysis at BWH, a primary goal of the LOS Task Force is the discussion of both “the plan for the day” and “the plan for the stay” occur for every patient on daily unit rounds.
Look for more updates on LOS and the other six areas of focus in the BWH Strategic Plan in upcoming issues of BWH Medical Staff News.