A blog dedicated to leveraging the power of data to empower consistent and persistent improvement in today's health systems.

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One of my favorite interview questions for a case manager is “What would you do if this hospital suddenly needed 15 free beds for an major incident?”

Invariably I would get a sort of devilish smile, and then the omnipresent admission, “Well, there are at least 15 people here who could go home today”. That means that almost every night all over the country we are being robbed of nursing capacity. Does this mean that we have a nursing shortage or bed crisis? Not exactly, but it does mean there is plenty of opportunity in the existing healthcare system to consistently serve many more patients. Serving more patients in the existing system is not just better for the patients and the community but has a overwhelming ability to cure the financial problems facing most hospitals.

The first problem is that we have to admit a problem. At a certain point, the decision to discharge a patient is fairly subjective. Once a patient enters the grey area of “able to be discharged” a whole host of factors come into play from the time of day that the physician makes rounds to the family’s ability to provide a ride home. Interestingly, when the hospital is under pressure to free up beds, especially when the hospital executives are personally engaged to free up beds, many hospitals are able to get every able patient discharged. In fact, if there is enough pressure applied even the borderline patients will find a way to the exits.

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Numbers should be the backbone of every business decision. Numbers guide decisions made, no matter the industry: financial markets, manufacturing, hospitals, even sports teams. Numbers alone don’t lie, but the wrong number or too many numbers can confuse and bewilder.

Some believe that for simplicity one number should be the indicator and but if this indicator is not well designed or used interdependently with other numbers, it can misguide. Management blindly focusing on the one number leads to poor decision making that fails to guide people to the intended results. On the contrary, using too many numbers clouds decision making; lack of focus, lack of timeliness, lack of confidence, all can combine to yield undesirable results.

For example, when looking at a baseball player if you only focus on his batting average you will not get the entire picture. If two baseball players had averages of .300 and .270 you would pick the player with the higher average if that was your only measure. Beyond batting average, the tactical decisions often include home runs, RBI’s, stolen bases and defense. There are situations where simple, yet complete information is needed to guide the decision in picking the best player for each situation. Likewise, some information such as home batting average during the day, how the player fields balls hit to his left, how he hits on grass fields, etc, could be interesting but not the key indicators.

The same is true of hospitals, there tends to be a fixation on length of stay as the only measure of patient flow. In fact, many scorecards are inundated with LOS trends and ratios (e.g LOS by DRG or LOS by Physician, etc.). Laser-like focus on length of stay can actually harm the patient flow effort because it tends to shift attention to a smaller percentage of patients, instead of the large number of patients that represent the bulk of the daily activity.

Often, LOS is a poorly designed indicator of patient flow; it is an imprecise daily snapshot of conditions taken in the middle of the night. When it comes to patient flow, minutes and hours count. There are material implications to overall patient flow if a patient is discharged at 11am vs. discharged at 6pm, however LOS cannot capture this reality.

Patient flow can be hurt if the staff is perpetually measured, rewarded and criticized on LOS. Every hospital has a few outliers that dramatically impact LOS. While these outliers might have economic consequences to the hospital, and should certainly get attention, the impact pales in comparison to the total impact of lost patient market share. In fact, losing just a few patients due to poor patient flow could easily negate a year of work on the outliners. As the CNO of a client hospital recently stated, “We are focused on the one barge stuck in the mud, instead of trying to clear the main channel.”

Consider that average LOS is unfavorably shifted to due to a small number of outliers. Outliers have great influence over the numbers, often their LOS is 5 to 10 TIMES longer than the typical patient; but, they often represent less than 5% of the total census.

Putting LOS as a priority leads the care team staff to spend their mornings working on exhausting all options to minimize the length of stay for the low number of ‘barge stuck in the mud’ patients, instead of prioritizing their time on the mainstream or ‘easy’ discharges; thus, the mainstream waits while the minority wait. If we were to truly focus on patient flow, the same care management team ought to prioritize their activities to ensure that the non-outliers, the typical patient is unencumbered through the DC process. Unfortunately, the NUMBERS DON’T GUIDE this BEHAVIOR.

With the primary indicator to drive patient flow being length of stay (LOS), a predicable pattern emerges: Famine and Feast -- essentially a non-existent supply of beds in the morning followed by a mountain of beds late in the afternoon, right around shift change. Unfortunately, the demand for hospital beds peaks about 4-6 hours before they are available, and then remains constant into the early evening. When demand remains constant and supply is created later in the day, there will be long waits in the emergency room and PACU, physicians who can’t find beds for their patients and ambulance diversion: resulting in inexplicable waiting, causing loss of revenue, loss of market share, damage to physicians relationships, loss of community support et al.

Imagine instead the power of working to shift patient flow to earlier in the day, without consideration to LOS. Now the care management focus is shifted from the difficult cases to the easy discharges early in the day, patients leave at an even pace throughout the day, smoothing out your supply of beds and meeting your demand. There is no extra work added, but just a change in the daily routine. Focus for the current day becomes easy discharges in the morning, followed by the more difficult discharges later and then working on the anticipated discharges for the following day. For example, if you are able to free up 3 beds early in the morning by focusing on easy discharges, you are able to move an additional 15 people through the Emergency Room, assuming 1 in 5 will be admitted. Small things can have a big impact in patient flow.

To implement this type of behavioral change you need to develop key measures that track the performance of the ‘main channel’ and keep the ‘barge’ numbers at the end of scorecard and out of the spotlight. Focus on labeling each patient as an easy, medium or hard discharge at time of admittance. Track the discharge percentage by noon as an indicator and make that the focus of rounds and meetings.

And how does this help the hospital? Because everyone wins. Patients are able to be seen in a timelier manner and receive the correct level of care. Physicians are able to place the right patient in the right bed and nurses have a patient that is happier and stabilized in a quicker timeframe. Administration is happy, because diversion is decreased or eliminated and patient satisfaction increases. And how is care management better off? Because, the unintended benefit of this type of behavioral change can be a decrease in length of stay without it being the sole indicator and focus of the care management staff. Working on patient flow CAN decrease length of stay, but focusing on length of stay CANNOT increase patient flow.

In light on increasing governmental mandates to measure and compensate based upon adherence and success in following the guidelines prescribed in the Sepsis 6-Hour Bundle, the data in your health system holds the power to not only dramatically decrease sepsis, but more importantly increase patient outcomes in the process. Sepsis is a growing issue and an expensive challenge for many health systems. In this introductory presentation Guardian outlines a strategy that can directly and immediately decrease Sepsis in your hospital and provide continuous improvement by using data analytics and a series of predictive prompts and alerts that help guide your knowledge workers.