The Space Between

Improving the efficiency and effectiveness of patient progression through the hospital saves money and creates an effective increase in bed capacity. For the VAST majority of cases, hospitals are paid a set amount for each patient based on diagnosis (DRG) regardless of time spent in the hospital. Finding ways of appropriately speeding the inpatient process, therefore, is a key component to decreasing healthcare costs and increasing capacity (without additional brick and mortar). Unfortunately, many hospitals and health systems don’t focus on the big issues affecting length of stay.

Acute Care facilities (aka hospitals) look at two metrics when thinking about patient beds: average length of stay (ALOS) and readmission rate (ReAd). ALOS can negatively impact a facility’s profitability by increasing their cost associated with the hospital stay – room, board, Nursing, Ancillary Services, treatments, opportunity cost, etc. A high ReAd rate, especially with Medicare patients (the majority of those in hospital beds), can lead to millions in penalty payments, shrinking the bottom-line even more.

The two have some interplay, since moving patients through their admission too fast can result in problems that lead to more readmissions. Of course, the best ways to avoid a readmission are: 1) don’t admit the patient in the first place, and 2) never discharge the patient.

Number one can’t get to zero, but this notion is what’s behind identifying patients with fragile chronic conditions and those with rising risks to intervene in ways that optimize health and minimize exacerbations that can lead to the need for hospitalization. In other words, good risk stratification, appropriate patient engagement/guidance, and robust programming to support them in the self-management of their chronic conditions or negative social risks.

Number 2 only works if you have an infinite supply of hospital beds.

So, that leaves us with trying to find the sweet spot of time spent in the hospital to get all the acute care needs addressed and the outpatient needs assessed and arranged to be met.

When considering ALOS, another metric we often look at to see where we are vs where we should be is Excess Days as an inpatient. This number looks at what the expected ALOS would be for our patients (based on a mix of risk and diagnoses) subtracted from our actual ALOS (or geometric mean length of stay – GMLOS – but that’s for another time).

We like to blame patient flow, census, and Excess Days problems on issues around the Discharge Process – delays from payers for skilled nursing (SNF) or home health authorization, delays in SNFs assigning beds, and so on. The reality is these account for a small fraction of the problem. 

It’s the Space Between where the largest potential for improvement lies.

Within that space lies opportunity like excess testing (lab stewardship), delays in test completion and resulting, unnecessary consultations, process and structure issues affecting therapies/treatments/interventions, clinical variation, physician delays due to patient load or rounding limitations, etc.

A multi-hospital system I once worked with calculated that they had 120,000 Excess Days in their system over a 12-month period. When we looked at the data, we found SNF delays accounted for around 4,000 of those 120,000 Excess Days.  A significant number indeed and a very visible delay, but only about 3% of the overall Excess Days total.

Their response to Excess Days had been to both blame the payers (see above) and to work on streamlining the Discharge Cycle – the time from Discharge Order to the patient leaving the bed. Their work on a pilot project yielded an improvement of Discharge Cycle time from a system average of around 6 hours to about half that.  An improvement of 3 hours on their 75,000 discharges annually would account for an improvement of 225,000 hours, or just under 10,000 Excess Days.

Fixing both issues to perfection would decrease Excess Days by 14,000, or almost 12% of the total Excess Days.  In other words, an Excess Days average of 2.0 would be decreased to 1.76 Excess Days.  That was with perfection, 24/7 discharges, and full participation of the payers and SNFs. Not likely.

Here’s the take-home message:  We can’t lose sight of the Space Between when trying to fix patient progression and flow issues (Excess Days). 

We need to identify and address the issues of excess testing (lab stewardship), delays in test completion and resulting, unnecessary consultations, process and structure issues affecting therapies/treatments/interventions, clinical variation, physician delays due to patient load or rounding limitations, etc. (Also look at which patients could have avoided admission in the first place with proper outpatient followup from the ED.)

Is it easy? No. But this space is where the rewards lie.