Background: Length of stay is an ongoing challenge for hospitals across USA. Large number of medically stable patients continue to remain in the hospital. There are multiple barriers including social, financial, and poor communication between team members. This delays discharge leading to poor patient care, burnout of team members, reduced bed capacity and access.
Purpose: With the long-term goal of decreasing length of stay and excess days per discharge, the purpose of this QI initiative was to mitigate barriers to patient discharge in real time by promoting interprofessional communication and coordination of care.
Description: In August 2022, an interprofessional team initiated an A3 to identify barriers for patient discharge. This process recognized several root causes for prolonged length of stay in our hospital including a lack of structured approach for mitigating impediments for discharge in patients with complex social and financial issues. Based on the need, the team first created weekly progression care rounds with the purpose of facilitating throughput for patients who were otherwise medically stable. Stakeholders included case management, utilization management, rehab, nursing, behavioral health and a physician advisor. Physician advisors had experience in navigating insurance barriers and were a liaison between the physician team and others. The rounds took place over a 1 hour zoom call, weekly. Any patient with documented barriers to discharge or stay longer than 30 days due to complex needs was discussed. Team created standard work which included structured discussion and key information about the patient guided by a designated facilitator. Facilitator ensured that standard work was followed. The team created a visual management tool in excel to guide the weekly rounds, ensure actions were recorded and followed. All team member and disciplines had access to this tool. This visual was shared and updated in real time. We noticed improvement in length of stay but still noted some gaps and delays given weekly rounds. The team initiated the daily Operations center huddle. An Operations center included representatives from various areas of the hospital. This helped multiple interprofessional teams operate as one unit, thereby increasing coordination and prioritization of care through interdepartmental collaboration. Daily morning huddles were conducted Mon-Friday. The huddles focused on quick, short updates and brought representatives from across multiple disciplines together. This led to better coordination and mitigation of discharge barriers.
Conclusions: Prior to initiation of these rounds and operation center, average length of stay at our hospital was 4.4 days with 1.7 average excess days per discharge. Following our interventions, average length of stay decreased to 4 days (9% drop) and average excess days per discharge decreased by 23% (1.3 days). The biggest impact in length of stay and excess days was seen in patients with stay greater than 30 days, identified as outliers with respect to length of stay. Prior to our interventions, average length of stay for our outliers was 98 days with 81 excess days per discharge. Post intervention, the average length of stay decreased by 25% (74 days) and average net excess days per discharge decreased by 20% (68 days). In addition, we have also seen an overall decrease in the number of patients identified as outliers at our hospital. Besides impact on length of stay, these interventions have led to improved communication and collaboration between team members.