Length of stay is not a problem - It's a symptom

by Stefani Daniels, Managing Partner
Published on May 24, 2018

It's time to turn the daily doses of negatively about length of stay into a conversation about quality and safety.

Length of stay is not a problem --- it's a symptom!

That's just the truth of the matter.  

I meet many hospital case management directors over the course of a year of travel and the issue of length of stay (LOS) is always a hot topic because of the pressure they feel from the C-suite. Unfortunately many find they are unable to counteract the deluge of noise that accompanies the typical call for action and the rationale offered by the executive team. You've all heard the arguments:  "The ED is backed up - get the patients out;"  "We're over the GMLOS and lose revenue unless we get patients out quick;"  "We gotta turn over the beds to keep revenue at budget expectations;" and "we don't get paid for keeping the patients the extra days."   Sound familiar? 

These decades-old arguments haven't had the intended impact and another generation of case managers, who, in many facilities, are typically charged with making discharge plans and executing those plans for an entire hospital population, learn the hard way that the job of hospital case manager isn't what they had hoped it would be. 

My colleague Ellen Fink-Samnick, writes that bullying in the hospital often takes the form of repeated intimidation by a superior.  Consistent haranguing by an exec to the case management or utilization review Director about the timeliness of discharges and the LOS is an uncomfortable form of bullying - one that eventually takes its toll and contributes to low morale, staff turnover and recruiting difficulties. But it doesn't have to be this way...change the conversation and turn conflict into an opportunity for improvement.

The fact is that length of stay is generally a product of two major variables:  Physician practice patterns and delivery of care processes. 

Physician practice patterns refer to the decisions physicians make regarding their patients treatment plans, the interventions they order, the timeliness of their patient rounding schedule, their decisions to discharge patients, and other variables that impact the avoidable time the patient spends in acute care.  Included in this category is the decision to hospitalize a patient whose care could be more safely provided in a less risky setting.  It may be the refusal by covering physician to discharge a patient; physician insistence that patient be discharged to specific post acute facility; reluctance to adhere to  evidence based guidelines adopted by the medical staff to avoid low-value interventions; lack of coordination between attending physicians and consulting physicians; ignoring patient/family preferences; delay in converting IV to po medications; duplicating diagnostics without documented rationale; and other progression of care delays resulting from physician practice decisions. 

Delivery of care processes refer to the ability of the organization to deliver care to patients in a timely, efficient manner.  Hospitals are notoriously inefficient and the list is endless with examples of obstacles to efficient progression of care from the time a patient is warehoused over the weekend waiting for a scheduled procedure, to delays in scheduling, completing and reporting the results of a diagnostic test; from delays in transporter availability, to the lack of a critical care bed; from the refusal of an accepting facility to admit patient after 3 pm, to a delay in processing paper work for a patient transfer; and from remedying incorrect demographic and insurance information which delayed discharge planning activities, to allowing payers to apply tactics to delay patient transfer authorizations.   

While length of stay is seen as a financial issue by the C-suite, by rights, it should be viewed as a quality issue that impacts the entire hospitalized population. Every clinician knows that hospitalization poses risk and that excessive time in an acute care environment increases that risk. The term iatrogenic is defined as "induced in a patient by a physician's activity, manner, or therapy" and iatrogenic disease is now the 3rd most fatal disease in the US.  Inappropriate hospitalizations and the attending physicians' decisions on diagnostic procedures and therapeutic regimens can unwittingly bring about iatrogenic disorders. This is the primary reason why physician practice behaviors and delivery of care processes must be addressed by the C-suite. When quality and patient safety become the cultural conversation in an organization, everyone will serve as a patient advocate and the 'symptoms' of excessive LOS will be remedied.