Analysis of factors affecting Length of Stay using CARE model- (A modified PDSA cycle) in a Community Hospital in North Eastern USA

From the 2019 HVPAA National Conference

Dr. Comfort Agaba (St John’s Riverside Hospital Yonkers, NY 10701), Dr. Paul Antonecchia (St John’s Riverside Hospital Yonkers, NY 10701)


Length of stay (LOS) is a metric used by hospitals to measure the efficiency with which they render care to their patient population[i]. Average Medicare LOS is calculated by dividing the number of Medicare patient days divided by Medicare discharges (excluding patients at the rehabilitation center). LOS is tied to reimbursement by CMS[ii], or rather is used as a disincentive, as hospitals are penalized for excess length of stay[iii]. In a Community Hospital in North East USA, the average Medicare LOS of 5.85 days in 2018 is higher than National, State and Cohort averages at 3.99, 4.24 and 4.12, and factors leading to increased length of stay were identified used the CARE Model.


To identify factors leading to increased length of stay in a Community Hospital in North East USA using the CARE model


The Care Model is a quality improvement tool developed as a modification of the PDSA cycle, where CARE is an acronym for:

Clarify the Problem

Analyze the causes

Remedy the causes

Evaluate the results

Clarify the Problem

Involves clarifying and mapping the processes that lead to patient discharge from the hospital.

The Flowchart is the Tool Commonly Used and an Opportunity Statement is the output.

Analyze the causes

The Advisory Board Committee, developed “Crimson Continuum of Care” which is a proprietary performance technology platform with the unique capability of integrating charge, cost, core measures, and physician quality data to create a severity-adjusted view of physician performance.

Using the data available from Crimson software, theories of possible causes were formulated and then root causes were identified using a Cause and Effect Diagram

Remedy the causes

Would involve considering alternative solutions, designing solutions, piloting changes and implementing solutions. Brainstorming would be the tool commonly used, and the output would be an implementation plan.

Evaluate the results

After implementing a strategy, tactic or process change that might remedy the cause, there would be a continuous process of data collection, performance analysis, impact measurement to ascertain if improvement has been achieved.


Data analysis showed an increase in LOS among private physicians (6.4) compared to the hospitalist/ teaching group (5.3).

LOS was longer among Medical patients, compared to surgical patients, and among respiratory neoplasms compared to disorders in other body systems.

Also, patients discharged to a rehabilitation center had a longer LOS compared to those discharged home, with or without a health aide.


The CARE Model, though also a four-point quality improvement tool, focuses more on root cause analysis prior to remediation, compared with the Plan- Do- Study Act which directly starts up with a plan. Among people new to quality improvement such as resident doctors, the CARE model provides a simplified but logical process for problem analysis unique to health care settings.

Clinical Implications

Using a more user-friendly tool such as the CARE model will increase the ease of performance improvement among residents and other providers.





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