Domain #3: Avoidable Days
When patients stay in hospitals longer than is medically necessary several derogatory consequences are felt:
- On volumes reimbursed on a "case rate" or DRG basis, unnecessary labor, supply and overhead expense erodes profitability
- Spot census is artificially heightened resulting in challenges to throughput, ED delays and expansion of risk (via sentinel events, infections, slips/falls, etc…)
- Overall length of stay is raised
- Potential "opportunity revenue" is lost (assuming that capacity challenges limit the ability to admit new patients)
This section allows an organization to assess the level of performance is has achieved in understanding and overcoming the variables that create, foster and enhance the effects of "avoidable days/delays".
Components of the Avoidable Days Self Assessment are listed below.
Case management only offers placement choices that are truly available to each specific patient based on their ability to pay, type of payor, care needs, specialty bed needs, etc…
CM/UM/Discharge planning staff members no longer offer patients the "choice" of sub-acute facilities that are unable to take them (due to insurance, financial conditions, bed availability or specialty care requirements).
Case management has evaluated and updated the true acceptance criteria of all rehab, LTC & SNF facilities in the community
CM/UM/Discharge planning department has developed a system to track and update the conditions of acceptance of local sub-acute facilities.
Case management works with finance on placement issues derived from equipment deficiencies at receiving facilities (to allow for cost benefit assessment of buying the equipment for the patient vs. leaving the patient in a hospital bed)
CM/UM/Discharge planning departments has weekly meetings with a senior finance/operations team member to ensure that patients don't remain in the hospital if it is becoming more financially efficient for the hospital to just buy specialty equipment/beds for the receiving sub-acute facility.
The organization has overcome any challenges in placing patients with derogatory payor types at their "wholly owned" facilities
The hospital has crafted clear policies that ensure that their own sub-acute facilities accept the placement of ALL patients whose care requirements can be kept regardless of the payor class of the patient (both advantageous and derogatory).
Case management has completed all placement activities 12-24 hours prior to anticipated discharge
CM/UM/Discharge planning team begins discharge planning activities upon admission and ensures that all pre-discharge requirements are met PRIOR to anticipated discharge date.
Organization of Care
Have improved alignment between employed physicians and organizational goals for LOS
The organization has developed physician report cards that report geo-mean LOS by DRG, house mean LOS by DRG & physician mean LOS by DRG in order to begin to educate physicians on the impacts of their practice patterns on both patients and the organization.
Have created prioritization for pending tests/procedures for non-emergent patients
Every ancillary department organizes non-emergent inpatient tests and procedures (including consults) from "closest to discharge" to "farthest from discharge" to ensure that discharge is not delayed pending test/procedure outcomes.
Are managing needed tests/procedures to ensure completion 36 hours prior to anticipated discharge
The organization has targeted an "anticipated discharge date" that is a minimum of 15% shorter than geo-mean (per DRG) and ensures that tests and procedures (including consults) are completed in advance of this "anticipated discharge date".
Have instituted a daily multi-disciplinary review of LOS outliers
The organization gathers representatives from nursing, CM/UM/Discharge planning and key ancillary departments daily to review the care progression of patients near or at their "anticipated discharge date".
Have created a "SWAT" team (that includes employed physicians) for overcoming delays in discharge
When necessary, the daily multi-disciplinary review team will escalate issues impacting the efficiency of care to a team of senior leaders who are empowered to make final decisions regarding care.
Have developed clear "roles & responsibilities" for all participants in care (nursing, case management, employed physicians, attending's, ancillary providers, etc…)
All departments involved in care are CLEAR on their role in ensuring efficient, quality care delivery organized around "anticipated discharge date" and changes in patient condition.
Are tracking patient outliers beyond 1 day variance from anticipated DRG based geo-mean LOS
The organization actively tracks, reports on and targets intervention on patients whose LOS has exceeded 1 day beyond "anticipated discharge date".
Are tracking "causes" of delays in care/discharge in a minimum of 20 categories
The organization tracks and reports weekly on "causes of delays in care" in discreet, actionable categories.
Are measuring delays in care/discharge in hourly rather than "daily" increments
The organization is measuring "hours" or "minutes" of delays in care rather than "days of LOS".
Reporting & Performance
- Outlier reports are generated daily and report hours of delay in both care and discharge.
- # of outliers (patients staying beyond medical necessity) has been reduced by at least 50%.
- # of cumulative outlier days has been reduced by at least 70%.
- Avoidable days due to placement challenges has been reduced by at least 70%.
- Med/surge volumes have dropped due to increased discharges.
- Overall LOS has dropped.
Labor Competency Domains
- #1) Staffing / Recruiting
- #2) Scheduling
- #3) Avoidable Days
- #4) Productivity
- #5) Process
- #6) Policy & Governance