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)
Background
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.
Objective
To identify factors leading to increased length of stay in a Community Hospital in North East USA using the CARE model
Methods
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.
Results
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.
Conclusions
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.
[i] https://www.beckershospitalreview.com/lists/224-hospital-benchmarks-2018.html
[ii] https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/acutepaymtsysfctsht.pdf
[iii] https://acphospitalist.org/archives/2014/10/los.htm
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