Reducing denied days, or days of hospitalization that aren’t reimbursed by payers, is critical for hospital financial stability, and to ensure efficient, patient-centered care. In 2015, payers denied payment on ~20% of all hospital days at LAC+USC Medical Center, a 676-bed safety-net hospital with a Level 1 Trauma Center. The Department of Medicine, which provides direct care for ~60% of patients, had 4979 of 20563 (24.2%) hospital days denied during our baseline period of July-December 2015, accounting for 53.1% of the total 9372 denied days (DD).


To reduce the DD percentage from 24.2% to 15% by June 30, 2017.


We categorize DD in 5 ways: Admission Denial, Level of Care not Justified, Non-MediCal Benefit, Service Delay, and Waiting for Placement. Analysis of 2015 DD found that Level of Care not Justified and Service Delay accounted for 1955 (39.3%) of the DD. As physicians have the most control over these types of DD, we focused our improvement efforts here.  We used PDCA cycles to reduce DD in these categories. First, we identified daily progress notes from Medicine services that did not justify acute hospital care. Then we worked with the physicians to ensure the documentation accurately reflected the actual events of patient care, and that if the documentation was accurate to encourage the team to move the patient along the continuum of care.  Next, we met with each Medicine service sequentially for a week at a time to discuss DD for that team. We reviewed the team’s DD accrued from the prior day. We discussed the denial reasons, and identified how the team can correct the DD and/or prevent a DD from happening in the future. As each team completed their weekly session, we moved to ongoing audit, feedback and coaching through the team’s nurse case manager. To sustain these efforts, we held daily huddles with the teams’ case managers to discuss and problem-solve the day’s DD, and held monthly huddles with the Medicine teams to educate and reinforce the importance of avoiding DD.

Through October 2016 Medicine teams accrued 6306 DD during 32360 total hospital days (19.5% denied). The average total number of DD per month fell from a baseline of 829.8 DD/month to 630.6 DD/month post-intervention. The percent of hospital days denied per month also decreased from a baseline average of 24.2% to 19.4% for 2016 (Fig 1). In particular, the rate declined even further from 720 DD/month between January and April post-intervention, to 571 DD/month from May to October (a 30% decline). The DD from Level of Care not Justified declined from a baseline average of 190/month to 53/month (72% decline) (Fig 2).  And the DD from Service Delays fell from a baseline average of 156.8/month to 84.9/month (46% decline) (Fig 3).


Structured audit and feedback (A&F) is an effective tool for reducing DD. In addition, our structured A&F mechanism allowed us to learn about inefficient care delivery processes that impact front-line staff regularly. Indeed, these A&F rounds often spawned small improvement efforts around specific service delays discussed during the A&F process. Although these improvement efforts may confound our results slightly, hospitals can use structured A&F with physicians to reduce DD.