Reduce Delayed Discharges and LOS to improve Cost and Performance
If your Length of Stay is greater than 4 days, then you have an opportunity for major improvement and savings by reducing discharge delays and excess LOS. Every time you implement a new practice to reduce delays they return in a matter of months or pop-up in another area. Quick fixes just don’t work. If you want to relieve the staff stress and the nearly $8 million in additional costs that come with excess LOS and Discharge delays, here are 12 steps that you should be addressing.
QUICK ASSESSMENT: Take a minute and rate your patient throughput capabilities, based on twelve key components. Rate each from poor (1) to prolific (5), where implementing the tools is a (3). Give this simple survey to a sample of your hospitalists, nurses and patients to get a quick baseline of your current situation.
Now total up your points, where a (1) counts 1 point and a (5) counts 5 points. If you score:
Below 35 = need to work quickly to implement and reinforce new behaviors across all areas
35-45 points = average – focus on improving your 1, 2 and 3s.
45-60 points = leading the industry, focus on automation to reduce manual coordination.
Reduce Inpatient Discharge Delays and Length of Stay - These 12 things all focus on reducing Discharge Delays and Length of Stay (LOS). If you are an average community hospital with a length of stay greater than 4 days and most inpatient discharges late in the day, then implementing these 12 things can cut $8 million in excess costs and stretch your available inpatient capacity by 20-25%.
CHANGING BEHAVIOR IS CRITICAL – These 12 things can be implemented without changing your EMR or making major process changes. The critical factor is changing provider and staff behavior to apply and sustain these actions. Without changing behavior these changes will NOT stick. So how do you create a positive environment that motivates providers and staff to change their own behavior? To be successful, you need to develop a Behavioral Science approach for effectively motivating people to adopt new, more effective behavior. Neither Six Sigma nor Change Management use behaviorally-based techniques. Take the time to effectively learn, change and reinforce new behaviors.
Focus on individuals, transactions and outcomes (rather than jobs, process and goals). Focus more on WHAT people do than how they do it. Highly skilled roles (such as medicine and nursing) require a high level of self direction and customization of work. Beware regimenting their work into an exact step-by-step process which will only denigrate them. Focus instead on a clear shared outcome for a specific action by demonstrating best practice. Once they agree on the outcome, action and best practice, they will work to integrate it into their practice. They may vary how they implement the new behavior, but that is fine as long as they achieve the desired outcome.
Focus on hospitalist-based care teams. Most community hospitals use hospitalists and Medicine (not Surgery, Pediatrics, OB or Psychiatry) drives most of the delayed discharges and extended LOS. As the leader of the inpatient clinical team they can prompt and reinforce the key activities that impact most discharges. An important part of adopting and sustaining new behavior is having a close team that works together consistently. This crucial step of creating individual accountability to a team and building effective care team coordination, behavior and routines at the bedside improves both discharges and patient outcomes.
Focus on Intake and Discharge activity: While intake and discharge activity only occurs at the beginning and end of the patient episode, they drive patient care and account for over half of the total patient work. The decisions made during admission and discharge planning have the greatest impact on patient length of stay and discharge delays. Focusing on effective admission and discharge behavior will start you successfully and provide a clear path to reaching the goal.
MAKE IT SIMPLE: It is best to implement capacity management improvements with simple tools, such as checklists, whiteboards, manual order sets, patient lists and job aids. Providers and staff will take ownership to use and develop “manual” tools, rather than imposing EMR systems changes. Once the tools stabilize and translate into common use across the organization, then transition them to automated tools in your EMR.
IMMEDIATE FEEDBACK AND REINFORCEMENT: Similarly, start reinforcing behavior with management recognition and weekly feedback that focuses on achieving the individual team goals, rather than computerized reports and stop light tables. Most of the outcomes and goals are not tracked by the EMR; so that system-based reporting is nearly impossible. Instead develop PC/Excel based weekly reporting for each of the components. Ask providers and staff to start tracking Discharge Delays and as a care team analyzing the underlying causes. Collect manual data DAILY and make the teams monitor and assess their goal achievement, such as:
Admission Orders available within 2 hours of admission,
Estimated Discharge Dates set within 8 hours of admission,
Accurate Patient Placements, requiring no transfers
Patient/Family Education completed within 18 hours of admission
Discharge Placement completed 24 hours prior to EDD
Patient transports to exit within 30 minutes of patient ready
Number and type of daily discharge delays by unit
The important outcome is that the care teams set their own SMART (specific, measureable, actionable, realistic and timely) goals for each of the key discharge activities and measure their progress DAILY to achieving the goals.
PILOT AND BUILD ON SUCCESS: Finally, developing discharge activities and behaviors is a team sport. Start with one nursing unit or care team to develop and refine the tools. Based on their success ask the initial care team to act as champions to share the behaviors, tools, goals and rewards across the organization. Use an Agile approach to build individual ownership and accountability by helping every provider and team member to change their own behavior for improved patient outcomes.
Inpatient Throughput and Capacity Management is a complex network of team activities and individual decisions. Successfully improving it is less about systems and more about reinforcing people’s behavior.