JHAH Hospital Length of Stay in Medical/ Surgical inpatient wards

From the 2023 HVPA National Conference

Fatimah Albeesh, Masters Degree in Quality and patient safety (Johns Hopkins Aramco Healthcare), Ahmad Qatrameez, Bachelors degree in Nursing, Rami Abdullah, Bachelor’s degree in nursing, Fahad Mulhim, Bachelor’s in Medicine

The Average Length of Stay (ALOS) is an important hospital indicator for assessing hospital management efficiency and patient quality of care. A shorter stay will decrease the cost by shifting the care from inpatient setting to a less expensive post-acute setting, it also increases the bed turnover rate which in return increases hospitals’ profit margin.

Address the complex operational /clinical processes and identify and evaluate system strategies to improve Average Length of Stay (ALOS) in Medical/ Surgical wards at JHAH Dhahran Hospital.  A target was set to decrease ALOS from 5.8 in 2019 to 5.5 in 2021 and onwards.

JHAH utilized evidence based criteria (InterQual) to monitor appropriateness of admission, quality of care, level of care and continuity of care. A root cause analysis was completed using the top 4 contributing reasons of increased ALOS (Fig 1), as identified in avoidable days report. The Case Management process map was optimized to standardize the Case Management workflow and communication processes.An initiative was taken of creating a central discharge multidisciplinary (Physical Therapist, Social Worker, Nursing, and physicians) daily meeting to identify barriers to discharge and expedite patients’ transition process. This was supported by the Utilization Review Committee (URC), a collaboration between case management and physicians. Quality Analytics team collated, monitored and reported ALOS to stakeholders on a weekly and monthly basis with analysis for discharging department’s performance.

Cause and effect diagram to analyze causes for prolonged length of stay (Avoidable days) was created to identify the main causes for prolonger stays and establish an action plan. (Fig 2)The interdisciplinary team governed by the URC, was able to identify process opportunities for improvement. Hence; the following was implemented:

Optimized the role of utilization management.
Enhanced communication process among the multidisciplinary team.
The complementary role between utilization reviewers and discharge planners were further enhanced by defining workflows.
Assigned a case manager to EMS to track Level of Care (LOC) appropriateness and care variation.
The process of transferring patients to Long Term Care Facilities (LTC) was streamlined t
Implemented Observation Level of Care.
Patients with prolonged LOS >= 14 days were discussed on weekly basis to plan their successful discharge.Updating and involving chiefs of services on the new changes implemented in the organization.
Collaboratively working with Home Healthcare team towards identifying improvement opportunities.

Results & Conclusion:
The ALOS rate at Medical/ Surgical wards at JHAH DH hospital was reduced from 6.4 in January 2021 to 5.6 in December 2021. Statistical Process Control (SPC) chart quarterly performance shows a reduction on the ALOS from 5.9 first quarter of 2021 to 5.5 2 Quarter 2022 (Fig 3). The SPC depicts a common cause variation and that could implicitly reflect on the process stability. However, it does mean that more collaborative focused efforts need to be in place to further improve the LOS.

Clinical Implications:
JHAH is continuing to monitor ALOS to sustain and build on its improvement; as more collaborative efforts needs to be in place to drive an improvement on the hospital ALOS.  The future plan is to link Utilization Management/Review with Revenue Cycle Management once it’s implemented.

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