3 Ways Hospitalists Influence Length of Stay
- David Alvarez, MD
I am the Chief Medical Officer of MDP Management, a Chattanooga-based hospitalist group serving health systems in the Southeast. Our focus is medical practice management that empowers physicians to provide the highest quality care, exceed goals and drive change in the hospital system, resulting in an exceptional experience for patients.
In other words, my job is to reduce length of stay (LOS). Shorter stays drive quality, efficiency, and patient experience. Nobody wants to stay in the hospital longer than they must, and hospitals don’t want patients unnecessarily occupying scarce beds and other non-reimbursable resources. As the most rapidly growing specialty in U.S. medicine, hospitalists are a dramatic success story at reducing LOS and costs while improving outcomes such as readmission rates.
Despite overwhelming evidence that hospitalists reduce LOS, I still run into confusion - even resistance - as to whether and how individual hospitalists can influence LOS. The most common pushback is that LOS is mostly the result of factors outside hospitalist control. I agree with this sentiment, but it is beside the point. Hospitalists have some influence on LOS, and so that influence is where we should focus our efforts. As a clinical administrator, my job is to bring out the best in my team.
There are countless ways hospitalists influence LOS. Here are three categories that may help facilitate coaching, collaboration, process improvement, and innovation.
Tip #1: Understand Personality
Personality is perhaps the most obvious (if sensitive) factor physicians own. Hospitalists who are more proactive and assertive tend to have shorter LOS. At a high level this phenomenon should be obvious, yet it manifests in subtle ways. It affects communication style with patients, caregivers, case managers, and other clinicians. It affects the timeliness, frequency, and verve with which physicians engage the aforementioned stakeholders in the discharge planning process, consults, diagnostics, and handoffs. Perhaps most definitionally, aggressive (vs. conservative) physicians are more likely to decide to discharge.
Assertiveness and aggression have downsides as well. Nonetheless, they are personality traits associated with lower LOS. For medical performance, awareness is far more important and effective than assigning “good” and “bad” qualifiers. Physicians that lean “aggressive” can wield their superpower, circumventing process bottlenecks and advocating for patients in complex situations. Physicians that lean more “conservative” can reflect on that fact during their next uncertain case, and proactively seek mentorship from opposite personalities.
At MDP, we incorporate this personality focus into our recruiting, retention, and development processes. We use a tool called SelectMD to profile personality types and explore how certain personality types correspond with outcomes like LOS. Any improvement requires an understanding of oneself, including our relations to our assignments and other people.
Tip #2: Leverage Case Management
In an ideal world, patient discharge plans are created as soon as a patient is admitted, responsibilities for this are clear, and our hospitalists’ only focus is getting the patient to health. However, this is not reality. In fact, case management is a two-way street between the hospitalist and extended care team. With all the competing priorities and grey areas, complex cases in particular can be real project management challenges.
As already mentioned, personality (of both hospitalists and case managers) weighs heavily here, as do local processes and conventions. I have seen a spectrum of roles, responsibilities, and assertiveness from case managers at the hospitals I and our staff have attended. In this matter hospitalists can play at least three roles:
- Coach: where case management is more assertive and has everything lined up - lean into them, start conversations, and convey information early.
- Pinch hitter: where case management teams are less proactive, step up to the plate. Often hospitalists can do things that are not required of them but can accelerate steps that need to happen (in or beyond the hospital). And hospitalists can always advocate for actions and decisions that will inevitably serve the patient’s care.
- Scout: in all cases, raise your hand when you see opportunities for greater efficiency. Advocate for a subtle change in shift schedules, flag the problem of SNF availability on weekends, clarify ownership of a “grey” (and thus missed) conversation between clinical or social work.
That third category is key, as hospital medicine is a team sport, and we are all collaborators in the effort to improve not just ourselves, but others and the systems in which we participate. We are currently advocating for one of our hospitals to pair individual case managers with service lines and individual physicians, which has worked elegantly at other systems.
Tip #3: Avoid Rabbit Holes
Some doctors tend to hold onto patients for reasons of curiosity or for a circumstantially expanded scope of the admission problem. For instance, a patient might say, “My back’s been hurting, doc!” when it has nothing to do with their reason for admission. Some physicians will go down the rabbit hole instead of allowing this care to extend to the patient’s home clinic.
Much of this workup unrelated to the core admission problem is attributable to how young the hospital medicine specialty is. Early hospitalists inherently held outpatient experience and instinctively knew what could and should be done in an outpatient setting, making them more well-rounded. Now, younger physicians finish up residency and go straight for hospitalist jobs, leaving them with skewed perspectives of the scope of care.
At MDP, we work 7-on-7-off shifts, and have traditionally paired physicians with people they like to be paired with. We are considering changing that, and intentionally pairing more tenured physicians (who often have more outpatient experience and are more likely to recognize what can be done in outpatient settings) with newer hospitalists.
This inpatient vs. outpatient dynamic is just a subset of a broader category of potentially unnecessary care. Any time consults or diagnostics are ordered, they serve as possible bottlenecks to discharge. While convincing physicians that certain care practices are never necessary is likely unwise and certainly a labor, discussing where necessary care can be delivered is an easier win.
In Conclusion: From Coaches to Collaborators
The bottom line is: LOS is a beast. Reducing LOS is a multifactorial problem, and hospitalists are just one piece of the puzzle: albeit an important one. Personality, practice style, and teamwork all matter, and all are sensitive topics that are difficult to quantify. Coaching, peer-to-peer collaboration, and targeted innovations can work in concert for improvement.
At MDP, we know who our “long-term keepers” are. Many are excellent physicians, aside from LOS, and their reasoning often originates from patient-centeredness: “I just do what my patients want.” Engaging hospitalists on anything related to LOS has to be a human exercise.
LOS coaching goes beyond top-down process or exhaustive checklists. I advise individualized shadowing and mentoring. Create forums where hospitalists gain transparency into each other’s practice patterns and practice styles, trading workflow hacks, experimenting with what works and what doesn’t. Learning in complex matters like LOS is rarely “heard”, more often “seen”. Data can play a key role, whether practice pattern data (as provided by Agathos) or psychographic data (as provided by SelectMD).
Ultimately, physicians decide whether or not a patient goes home. We can all consider the role of our personalities, more proactively enlist our teams, and steer clear of unnecessary care.