When I arrived at a 150-bed hospital as their new Chief Financial Officer, one of the key performance metrics that I immediately became concerned with was the inpatient length of stay (LOS). Our average LOS ranged from one to three days longer than what payors expected. I encouraged my staff to know the expected length of stay for each of their patients, determine why their patients were staying longer than expected, and work toward establishing protocols that would eliminate excess days.
During the first meeting with the Chief Nursing Officer (CNO) and several Clinical Directors concerning excess days, I emphasized my directives and rationale. Immediately I was informed that nurses could not be expected to know the various payor plans and expectations, and that nurses did not design treatment plans based on a patient’s financial class. Their job was to care for each patient based on what was needed to get the patient well enough to discharge to home or another level of care. The meeting ended more quickly than I had hoped.
Later on, I asked the CNO to meet with me again to discuss LOS and help me better understand what we could do to make improvements. During this meeting, we agreed on the following points:
- Nursing would be willing to use one LOS standard for setting an expected discharge plan. The plan was for nursing and case manager collaboration with proactive discharge planning and identification of discharge barriers if patients exceeded expected LOS.
- Some payor plans had LOS expectations and others did not, while still other plans were resistant to providing post-acute services. Expecting some payors to help with managing LOS would probably result in disappointment.
- The bulk of the patients were Governmental, Medicare and Medicaid – these payors represented 85% of total volume.
- Significant variances existed between insurance plans for expected LOS. For example, Medicare might have an expected LOS of four (4) days, while the same diagnosis for Medicaid was nine (9) days.
- Finally, it would be best to make this a patient care issue, not a financial issue, comparing all patients based on one standard, similar to how we would compare their clinical care without care of financial class.
The CNO and I decided that what we needed the nursing staff to provide quality care for the patients and determine from a universal standard, whether we were able to meet the expectations of the payor. Once achieved, we could then examine developing internal protocols based on the physician and facility standard of care, incorporating community needs to provide both a better quality of care in an appropriate period of time, which may or may not match the current norm.
Our first task was to identify a standard that made sense to us. We chose Medicare due to the following reasons:
- They were the largest payor, not only for our facility, but also for most acute care facilities in the country.
- It was easier for HIM to assign a DRG to all inpatient accounts, since the majority of payors used DRGs and we could run each account through our 3M Coder for an appropriate DRG assignment.
- Many of the other payors based their standards and billing requirements on Medicare.
We then designed a report that included the Patient Name, Account number, Medicare DRG, expected LOS, and actual LOS for the case management nurses/ discharge planners to review, and also allowed Physicians, Hospitalists, other Clinicians, Nurses, and HIM employees to use this same report to assist them in their day-to-day patient care and reviews. The report was printed out before each shift and given to the case managers and a copy was placed at each nursing unit.
Later, we also found that it was critical that we have concurrent coding occurring throughout the stay to ensure that any change in patient care and status was reflected in the expected LOS for the service being provided. What we were missing was a good way to track our progress other than our facility’s stats for LOS each month compared with the expected LOS.
How could we have tracked our performance to better understand if we were making a difference? If we had had the availability of an analytics platform, such as ClinView®, it would have been easy. Assigning all inpatients a Medicare DRG, would have enabled the facility to identify the excess days, while comparing all patients based on the same standard. Then leadership could have examined the excess days by unit, physician, DRG, etc., and either work toward implementing protocols to improve LOS or determined what was causing the patients to stay longer than the geometric length of stay.
Here are some examples of questions that should arise from such a review:
- Are we providing the quality care needed for the patient in an expected period?
- If not, what is causing the excess time of care?
- Have we reduced the actual LOS to expected LOS while still providing high quality care?
- How have our efforts influenced seven and 30-day readmits?
- What effect are we seeing in documentation and DRG assignment?
As you progress in making changes, more and more questions should arise that an actionable analytics platform can help to resolve. At the end of the day, the goal should be to provide quality of care for all patients in an appropriate period, resulting in less readmits and a healthier community.
It is important to have a plan, but it is as important to have an analytics platform to track and monitor your results. As a CFO, I would recommend ClinView to facilities that currently do not have the ability to track their results in aggregate, or the ability to drill down quickly by units, physicians, service lines, etc., to isolate areas of opportunity.
To learn more about how ClinView can improve the efficiency of your facility and receive a free online demo please click here: http://www.clinview.org/signup-for-online-demo/