By David Alvarez, MD, Medical Director, Hospitalist & Agathos Advisor
As a hospitalist and medical director, I understand a physician’s decision to discharge a patient is often not black and white. Clinical, operational, and social factors impact both physician and patient readiness for discharge and occasionally result in a higher than necessary length of stay (LOS). In addition to its cost and efficiency impacts, unnecessarily high LOS can have a negative impact on patient outcomes like readmissions and HAIs (hospital-acquired infections). Analytics at both the group and individual physician level can help hospitalist groups uncover previously hidden LOS drivers. Reliable data can empower physicians to test and measure validated means of optimizing LOS while maintaining or improving patient outcomes.
Recent analysis of our group’s data revealed three opportunity areas for optimizing length of stay that align with the latest academic research and our clinical instincts.
Support handoff improvements
Our hospitalists work seven-days-on, seven-off shifts. Tuesday is our handoff day, when each hospitalist inherits about eighteen new patients, contributing to over 200 total handoffs that day. Our group has about a 10% lower discharge rate on Tuesdays compared with Wednesdays through Fridays (Mondays, the day before handoffs, are also relatively low). This lower-than-average discharge rate on handoff day, partly inevitable, is in part attributable to clinical uncertainty from inadequate information transfer or cautionary decisionmaking. Checklists and standard handoff processes can improve handoff efficiency and quality, as well as physician satisfaction. In addition to improving handoff quality and continuity of care, our group plans to test staggering patient handoff days with the hope of reducing the operational bottlenecks. ACP Hospitalist’s December 2016 cover story offers a longer list of handoff QI projects for those who are interested.
Photo by Blogspot
Maintain optimal caseload
As physicians, we know that when our daily caseload goes beyond a certain point, our ability to make wise medical decisions plummets. It is pretty simple how hospitalist’s workload impacts quality and efficiency of care; as workload increases so does LOS. It may seem counterintuitive, but the more patients you have, the more likely you are to hold onto them. Our group has found eighteen to be the ideal number of daily encounters; any more and we see a negative impact on LOS.
Set expectations with patients (and early!)
In my experience, patients who want to go home will go home nine times out of ten. Setting discharge expectations from admission on is a major contributor to timely discharge. A patient’s psychological readiness for discharge matters and hinges on clear communication from all members of the care team. Most patients simultaneously feel uncertainty, fear, and a longing to return home, which must be coached throughout their hospital stay. Setting expectations also impacts patient satisfaction (“satisfaction” equals “reality” minus “expectations”), so there is one more reason to prioritize early discharge conversations with patients.
To effectively implement QI initiatives around handoffs, caseload, and setting expectations, groups should establish trusted methodologies and metrics, set a baseline, and track process over time. Furthermore, physicians need actionable insights to improve their performance across these QI initiatives and others. Successful QI initiatives rest of physician engagement and shared purpose around improving the quality and efficiency of patient care.