PHLO

Length-of-Stay: An Inadequate Measure of Patient Flow

By: Matt Carroll

Numbers should be the backbone of every business decision, no matter the industry. Unfortunately, using the wrong number or too many numbers creates confusion and bewilderment.

Using only one number on which to base a decision can be misleading, particularly when this indicator is poorly selected or it is not used in conjunction with other key measures. On the other hand, using too many numbers can cloud decisions by creating a lack of focus, lack of timeliness, and, ultimately, a lack of confidence.

For example, if a team manager focuses only on a baseball player's batting average in his selection process, he will miss a lot of other valuable facets in the player's game. If he considered two baseball players with batting averages of .300 and .270, respectively, he may choose the player with the higher average. But we all know that there are other important statistics, including home runs, RBIs, stolen bases, and fielding percentages, that should guide his decision in selecting the best player for his team.

Then again, some information, such as home field batting average during the day, how the player fields balls hit to his left side, how he hits on grass fields, etc., is interesting, but not essential to the selection process. This is simply too much information.

Let's apply this same kind of thinking to the hospital setting, where managers are fixated on length-of-stay (LOS) as the only measure of patient flow. In fact, many hospital scorecards are inundated with LOS trends and ratios (e.g., LOS by DRG or LOS by physician, etc.). But this laser-like focus on LOS 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 a hospital's daily activity.

Worse, LOS is a poor indicator of patient flow because it is an imprecise snapshot of conditions taken in the middle of the night. When it comes to patient flow, what's important is the time of discharge; in other words, hours count, not days. If a patient who could have been discharged at 11 a.m. actually left at 6 p.m. and the hospital was on ambulance diversion for three hours between 11 and 6, the LOS measure would not push this issue to the surface. But adding an indicator that tracked percentages of discharges by noon would.

From another perspective, patient flow can be hurt if the hospital staff is perpetually measured, rewarded, and criticized on LOS. Every hospital has a few outliers that dramatically impact LOS, and while these outliers might have economic consequences to the hospital and should certainly get attention, their impact pales in comparison to the total impact of lost patient market share. 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. In fact, losing just a few patients due to poor patient flow could easily negate a year of work on the outliers. As the CMO 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."

Making LOS a priority leads the care team staff to spend their mornings exhausting all options to minimize length-of-stay for the low number of "barge-stuck-in-the-mud" patients instead of spending their time on the mainstream or "easy" discharges. Thus the majority of patients wait while the minority of patients receives a disproportionate amount of time and attention. If the same care management team were to truly focus on patient flow, they would prioritize their activities to ensure that the non-outliers, the typical patients, are unencumbered through the discharge process. Unfortunately, NUMBERS don't guide this behavior.

When the primary indicator for driving patient flow is length-of-stay (LOS), a predictable pattern emerges: famine and feast. A dearth of available beds in the morning is followed by a mountain of beds late in the afternoon. Unfortunately, the demand for hospital beds peaks about four to six 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. This results in inexplicable waiting, which leads to loss of revenue, loss of market share, damage to physicians relationships, loss of community support, and so on.

Imagine shifting patient flow to earlier in the day, without considering LOS. Now the care management focus moves from the difficult cases to the easy discharges early in the day. Patients leave at an even pace throughout the day, smoothing out the supply of beds and better meeting demand. There is no extra work added, only a change in the daily routine. Focus for the current day becomes the mainstream 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 three beds can be freed up early in the morning by focusing on the mainstream, an additional 15 people can be moved through the Emergency Room, assuming one in five will be admitted. Small things like this can have a big impact on patient flow.

To implement this type of behavioral change, it is critical to develop multiple key indicators that track the performance of the "main channel" and keep the "barge" numbers at the end of scorecard and out of the spotlight.

When this happens, patients are 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 happier patient who is stabilized more quickly. Administration is happy, because diversion is decreased or eliminated and patient satisfaction increases.

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.

If you want to know more e-mail me at matt.carroll@usccg.com

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The Unintended Consequences of a Focus on Productivity

 

"Productivity" is one of those concepts hospitals have borrowed from manufacturing because it works so well in that environment. But in hospitals, productivity presents a paradox. Most practitioners in hospitals don't understand the principles behind productivity. As a result, their efforts to be "productive" will likely adversely affect critical elements of the patient experience and potentially the hospital's financial health.

The problem is that productivity is a relative measure that, when used as a sole indicator, can be very misleading. The number of dollars expended per hour for a specific activity, for example, is a productivity measure. These relative measures are designed to give managers and leaders a tool to help guide analysis and exploration. They help navigate and provide perspective. But, allowing productivity to be a primary analysis tool and decision making driver can bring about an undesirable result.

In the interest of full disclosure, I am a manufacturing engineer by training and I think some of my brethren own some of this mess. The patient-to-nurse ratio, the most famous productivity measure, is a perfect example. The med/surg ratio in many hospitals is 6:1. As relative measures go, this makes some sense – for establishing budgets. But it is a poor tactical management tool.

Productivity measurements like this one are insufficient when used to drive daily performance. Armed with the staffing ratio, hospital managers make day-to-day and even shift-to-shift decisions. It happens every day in capacity-constrained hospitals where managers are armed with only experience and a productivity measure. They take steps in the interest of meeting a target, but the following scenario will demonstrate how negative these decisions can be – all in the name of productivity.

At 9 a.m. a nursing manager with a 5:1 ratio has six nurses on shift, but only 25 patients. So, she decides to send one of the nurses home or to another unit. Assuming the fully loaded cost of a nurse is $75/hour, this manager has just "saved" her unit $75 for each hour of the nurse's 10-hour shift, or $750. Since that "productivity decision" is usually not made with the discharge requirements in mind, the decision to reduce staff can result in poor patient flow, highlighted by bed constraints, excessive delays in the ED and PACU (potentially impacting quality), or even ambulance diversions (which translates to lost revenue).

The $750 saved slows the patient flow and eventually costs the hospital somewhere in the low five figures of lost revenue for that day. Worse, the attendant long-term effect of the loss of confidence among doctors and the community could easily translate into losses in the millions over the course of a year. Beyond that, the lack of consistency in schedules is often a quality-of-life issue that leads to chronic problems with staffing and retention.

So the unintended consequence of saving that $750 by managing to productivity measurements alone is multiplied on numerous fronts, all negative and much more costly. Be on guard against managing your hospital's operational effectiveness with only a productivity ratio. No one wants his physician to base a diagnosis and treatment plan solely on blood pressure measurements. The same goes for hospitals and one-dimensional approaches to effectiveness.

Contributing to this work is Kenneth P. Staresinic

 

The worst thing to do in a capacity constrained hospital

Hospitals are complex logistical systems. Beware seemingly easy fixes to pervasive problems.

For example, CEOs at the helms of seriously crowded emergency departments constantly receive internal proposals for adding resources. Whether it's for a new building or more staff, a moment of pause is in order before approving such additions. In fact, it's important to recognize that adding resources could unintentionally aggravate an already troublesome situation.

Recently, I met with an executive who was struggling with patient throughput. The problem stemmed from an inability to discharge patients in a timely fashion. When the executive dug into the problem, she discovered that the vast majority of discharges where occurring at shift change (a common problem all over the country).

After a great deal of discussion and brainstorming, the idea of hiring a dedicated discharge nurse surfaced. This was considered a winning proposition for everyone on the unit because:

1. Nurses would be freed from a paper-intensive process to maximize the time they spend providing patient care;
2. Bed management could rely on a person who was accountable for ensuring that the beds where cleared as soon as possible;
3. Nurse management had a more consistent process for moving patients out;
4. Case management got a resource to help coordinate and plan their activities; and
5. Administration would solve one of the biggest challenges facing patient throughput, which would logically lead to even greater throughput.

A discharge nurse was identified and placed in the high-volume 35-bed med/surg unit. But, to everyone's consternation, the average discharge time moved to even LATER in the day. Why?

Previously, this unit averaged seven to ten discharges every day. With a 6:1 patient-to-nurse ratio across a 24-hour period, this meant that each nurse would be accountable for one or two discharges per day…and these discharges most often occurred between approximately 10 a.m. and 8 p.m. In this scenario, many people processed discharges, each independent of the others. Each had her own path to discharge, as illustrated in the chart. Thus, if there were a delay or a problem with Patient B, then Nurse B would have to deal with it. None of the other nurses or patients were impacted.

When the discharge nurse arrived, she was saddled with all seven discharges, and, in theory, she had the capacity to discharge all the patients in a timely manner. What wasn't considered was the fact that all the discharges immediately became interdependent. As such, any delay with any patient would automatically impact the rest of the patients.

This is just one example of how a seemingly good solution can actually create a worse problem. Take time to carefully consider the broad ramifications of changes to the hospital environment.

Medicare Changes Demand Hospital Makeovers

    The assault on the Medicare program now pointing toward one of the fundamental disconnects between healthcare and the rest of the business world. In the original federally controlled program, hospitals were actually financially rewarded for poor quality. They were frequently paid for the now-called "never events"

Under the new state-controlled versions, quality is no longer simply a moral imperative; now it's a real pocket-book issue for every hospital. Medicare will no longer pay for those "never events," or a lot of other things. Reforming the Medicare system to save money, has gone to the next level, demanding higher quality from service providers.

To thrive in this much harsher economic climate, hospital executives must revisit their hospitals' performance drivers and understand and anticipate how this economic change should be folded into the larger management system.

There are five areas that require close examination.

Strategy: How can the hospital's strategic direction change to make operational quality a competitive advantage in the marketplace? How can services that do not deliver superior quality be walled off or eliminated?

Process: Resist the default diagnosis that your hospital has a process problem. Most hospitals have a process control problem. Take steps to better control your processes. This isn't magic, but it does require knowledge of control systems, something they really don't teach you in medical school.

People: Now, more than ever, hospital employees must be multifaceted. Examine the hiring criteria to ensure that your hospital acquires the quality people who can deliver the quality that will drive success. It isn't trite, good people trump many problems.

Culture: Does your hospital culture tolerate the lack of discipline that leads to poor quality? Do you have a system that drives accountability throughout the organization? Do you put clear, actionable information in the hands of the people who need it? Are the targets clear and relevant to the individual? And is there a mechanism in place that instigates improvement when the organization's performance doesn't meet established standards? Does your culture serve the whole hospital?

Organization: Can the people in your hospital make decisions? A fundamental flaw in management today is the lack of importance placed on decreasing number of people who need to be involved in decision-making. A preventable problem is only preventable if people can act in time to prevent it. If you truly want your people to keep you out of trouble, they need to be able to act on information provided when and where they need it.

Changing the mindset of hospital executives and staff is a tall order, but not insurmountable. There are plenty of tools, techniques, and expertise available to put them over the top.

Trusted Advisor: Key to Technology Project Success

 

If your hospital is undertaking a major information technology project, get a trusted advisor to help you navigate the complexities -- someone who is impartial, has no political axe to grind, and has the skills to conceive and architect a system that'll work for your hospital. A trusted advisor will be hard to find, but will pay for themselves ten times over.

Among the important traits a trusted advisor brings are:

 

1. Demonstrable comprehension of your hospital operations. They don't have to be a doctor or a nurse. In fact, deep clinical skills can often be an impediment to your endeavor.
2. An understanding of how enterprise software works. Can she talk to the IT people? You're not looking for a 'geek', but a technology executive, a person who knows what it takes to build a system at the detail level.
3. A strong decision-maker. You don't want someone who consistently delivers a menu of choices and asks you to choose one. The trusted advisor is a person who can summarize assumptions, validate them, and make a decision. This is a person who can keep hospital executives informed, but not drag them into decisions where they lack expertise and shouldn't be the dominant voice.
4. The great communicator. Making decisions is the easy part; the hard part is selling them to the staff. The trusted advisor must have excellent communications skills.
5. Has vision. Too often technology is deployed to satisfy today's requirements, which isn't good enough. The healthcare business is highly dynamic and adaptive, so the trusted advisor should be able to foresee the future in order to devise a system that can support future requirements. They should be a 'visionary' who can balance today's reality with many future scenarios and still control the project economics.
6. Trustworthiness. The skill set already described here is important, but the hospital executive must be able to trust the advisor with his professional life and the often-huge investment the hospital is making. Beyond the 'gut-feel' of establishing trust, here are three questions to ask yourself when seeking a trustworthy advisor.

 

1. Do you look forward to spending time with this person? You're not looking for a friend, but you must be able to talk to this person informally.
2. Does this person command respect?
3. Does this person understand your risk profile? Your advisor should know YOUR limits instinctively.

 

 

Once you find your trusted advisor, listen to his advice!

Considerations before the next big system project

Electronic health record (EHR) projects are moving to the top of the executive agenda at hospitals, but major system deployments in healthcare fail far more often than they succeed. It might be useful to consider these insights before you start your next big systems project.

 

1. Stop looking at demos. Demos are a software vendor's game. The last software demo I saw, the salesperson practically promised that the software it could wash a car. Software demos offer little opportunity for pragmatic evaluation of capability. Your 'requirements' will almost always be 'possible' if you pay. And of course, most of the cost of big systems is ultimately in the installation and configuration phases, not in that base package demoed in the conference room.
2. Forget your title. Too many executives misuse their power when it comes to technology projects. Of course you want to ensure your investment is working, but, when it comes to big system projects, huge mistakes are often the result of combining organizational clout with a lack of understanding. No one every listened their way into a failed project.
3. Find a trusted advisor. Major information technology projects are infrequent, and they are expensive endeavors. This makes them worthy of an impartial, trusted advisor. Find someone with no political ax to grind, and with the skills needed to conceive and architect the solution. These people are tough to find and expensive, but they pay for themselves ten times over. The important thing is to listen to their advice! (More on this next week.)
4. Define the outcomes you want to achieve. Top executives who have spent untold millions on electronic health records are openly wondering why. Always define your goals in terms of outcomes. Technology has to improve your business, keep the focus there.
5. Hold you advisor accountable for the outcome, not project milestones. Have your advisor put the plan and budget together that achieves your objectives and then hold her to it. This sounds like common sense, but too many executive project debriefings include too much technical minutia. Pay attention in the project updates meetings, but focus on key performance indicators (KPIs) that point to the desired outcomes, not the project milestones.
6. Clear the field. Hospitals are notorious for trying to achieve comprehensive agreement on every decision. You aren't going to get the full benefits of major new technology platforms without ruffling a few feathers. Relax! Anyone worth their salt appreciates a disciplined work environment and the challenge of achieving excellence. The stories of Vince Lombardi (Green Bay Packers) or Herb Brooks (1980 USA Olympic Hockey Gold Medal) are legendary and no one complained about being on those teams. Have the courage to stand up to those who behave irrationally or are labeled "resistant to change" while you're trying to improve the hospital.
7. Spend the money on the basic infrastructure. Major systems projects are big money projects and ought to provide a dramatic return on investment. Unfortunately too many executives try to save a few nickels by deploying state-of-the-art technology across a crumbling infrastructure. If you want people to use these new tools, get out the checkbook and buy the computing infrastructure needed to run them: servers with lots of RAM, fast CPU, reliable & up-to-date PCs, high speed networks, superior backups, security, et al. Spend the money on the infrastructure or don't do the project.

    

See these related articles:

Click hear to read about UK's 24 BILLION Dollar "Prescription for Disaster."

. Click here to learn about how some doctors believe that EHR actually increase the chances for medical error

Why RFPs Fail Hospitals

 

Some hospitals rely on the Request for Proposal (RFP) and its kin, the Request for Quote (RFQ) and the Request for Information (RFI), to evaluate potential management consulting firms. Although these purchasing tools may seem a fair way to compare the companies' capabilities, it is difficult to imagine how their selection criteria could possibly provide the kind of insight needed to choose the right management consultant.

Here's why:

1. The single biggest factor in a successful relationship between a hospital and a consulting firm is the cultural fit among the people who actually do the work. This fit can only be ascertained in live meetings.
2. In the complex purchase of consulting services, it is nearly impossible to provide enough detail in responding to the RFP to get beyond generalities. The best consulting firms provide products designed specifically for their clients in response to clearly articulated requirements. Using the RFP process simply increases the likelihood that a hospital will exclude the one firm that might do the best work for it.
3. Prices delivered by RFP are ballpark figures at best. Any firm worth its fee will dive into the specifics of an engagement – the hospital's strategy, culture, technology, organization, processes, patient mix, physician mix, etc. – before presenting a fixed price. This is an opportunity not generally offered in the RFP process.
4. Beware of comparing your fees to those charged other hospitals. Your hospital is different, your needs are different, and your fee should be different.
5. References don't tell the whole story. Calling references doesn't protect hospitals from making a bad decision. At the RFP level, hospitals aren't really equipped to drill down into a vendor's references to reap the information that truly would be useful in the selection process.
6. Management consulting is a highly fragmented business. The typical company is a private firm with ten employees or less. These firms are rich sources of innovation, but the typical RFP excludes them in favor of the bigger, more financially stable, and more expensive firms that tend to recycle the same methodologies for every client.

Here are some alternatives to consider.

1. Re-direct the consultant's time to your benefit. It takes considerable time and effort for consulting firms to identify business opportunities, respond to an RFP, follow up, and win the business. Instead of the RFP, offer the potential consulting firms a chance to deliver something of value to the hospital. Ask them to conduct a study or provide some specific insight. This gives you the opportunity to meet the people, get a sense of their culture, and get something of value no matter your ultimate decision. And it's a far better use of everyone's time.
2. The only question to ask a consulting firm's references is "Would you hire them again?" References should be used only to validate what a consultant has told you.
3. Look at your team needs instead of the consulting firm's client list. Hospitals are full of very smart people, so most hospitals have about 75% of the solution to their problem in-house. Management consultants should be used to round out your team, not duplicate it.
4. Be very specific about the help you need. Is it technology? Clinical insight? Process? Strategy? Just because a consulting firm helped some other hospital, it doesn't mean it can help you. Every hospital is different.
5. Agree on an outcome, not a price. The potential ROI for operational improvement in a hospital is enormous. Make your consultant present a plan for achieving an ROI of 5:1 or better and hold him to it. A definitive scorecard is good for both sides.

Benefits of shifting hospital focus from admissions to discharge abound

Most hospital operations are organized around admitting, which means that everything is geared toward getting patients moved into a bed. Practically everything in the hospital revolves around admissions: the priorities, the infrastructure, the processes, the measures, the staffing levels, the training, and even the attitude and culture.

    To be sure, this approach is time-tested, but the reality is that, when the hospital is full, this method can strangle patient flow.

    The system starts to break down when a lot of patients pile up waiting for an inpatient bed. Waiting patients is a chronic problem for hospitals. And, when the queue forms, hospital management inevitably mobilizes to "fix the problem." Phones start ringing and managers, directors, or administrators start walking the hospital in search of beds.

    Hospital management usually handles fixing this problem because no one else has access to the information that defines the true state of the hospital. It takes time to manually collect reliable information on patient/bed status, so managers frequently find themselves investigating, expediting, and firefighting. This often pays off in the short term, because the bed crisis is always – and eventually - solved when patient discharge is expedited, a hidden bed is uncovered, or a physician is called to action.

    However, the core problem underlying the bed crunch has not been resolved. So the expediting culture becomes institutionalized, breeding the kind of inefficiency and bureaucracy that has well-intended professionals actually slowing patient flow. This results in a vicious cycle that leads to lower bed capacity and new unintended problems with trust, accountability, and confusion.

 

These problems are more preventable when the focus shifts to discharging patients

 

    The only way to prevent an overload of waiting patients is to have clean beds available. By focusing on discharging patients who meet the criteria for being sent home – regardless of the status of the hospital or non-clinical issues – the hospital will actively prevent the overload condition by systematically moving patients through the hospital.

Changing the focus to discharge puts the census in a new light. Too often in hospitals a patient stay is colored by such non-clinical conditions as socioeconomic issues, familial matters, or physician whims. A hospital passive about discharge tends to leave these decisions unchallenged, until the hospital is full. Then, with expediting, patients who lack the conditions that necessitate hospital care are discharged —sometimes abruptly. This is losing proposition for nearly everyone involved and a situation that is preventable.

With a simple change in focus, the entire hospital becomes organized and geared toward anticipating the action necessary to consistently and safely discharge every patient that meets appropriate criteria. This approach frees up bed capacity before it is needed, smoothing out workflow and optimizing patient placement.

    Equally important, the hospital permanently resolves the expediting problem. If the hospital sticks to its creed of discharging every patient that meets the criteria for being sent home, then, by definition, when the hospital is full, it really is full.

In addition, because patients have been moved proactively through the hospital, the common "bed crunch" expediting becomes needless. Eliminating the constant expediting will result in a dramatic improvement in staff satisfaction by relieving the stress of constantly being in crises. Patient/bed information will be truly trustworthy and the entire staff can become more effective, improving organization confidence and accountability.

It might seem like magic, but a simple change in philosophy can have a huge impact on hospital operations.

      

    

Why length of stay is a poor measure of hospital performance

Nearly every hospital measures and manages its performance based on inpatient length of stay (LOS). But LOS as an absolute measure really doesn't provide much useful information for managing a hospital. Here is why:

 

Lack of clear-cut root causes undermines accountability - Who is ultimately accountable for patient length of stay? The nurse? The doctor? The lab? The hospital administrator?

 

There are many reasons patients are in the hospital and, in an ideal world, objective clinical criteria would govern census. However, in the real world, there are statutory, socio-economic, familial, emotional, and even political drivers that affect a patient's status. It is nearly impossible to objectively determine root causes for excessive LOS because each patient's circumstances are so different, making root causes tough to classify and hard to analyze for better management.

 

In the absence of clear-cut root causes, no one member of the hospital staff can be held accountable for controlling LOS. As a result, lack of individual accountability makes everyone accountable; and, when everyone is accountable, no one is accountable.

 

Imprecise Measurement - Hospitals measure length of stay by the day. It doesn't matter to them whether a patient is admitted at 10 AM or 10 PM; any admission before midnight counts as a day. Since when does two hours constitute a day? Measuring length of stay this way is imprecise and dilutes the power of the metric. Wouldn't it make more sense to measure length of stay, with its attendant costs, on a rolling 24-hour basis?

 

That practice is already at work with observation patients. As an observation patient approaches the 24-hour target, doctors, nurses, and case managers are all actively managing the patient to either admit or discharge regardless the time of day. In this case, the target is met because there is a clear, unambiguous goal and patients on this 24-hour clock tend to be (decisioned? or have their status resolved?) discharged in 24 hours. LOS would be far more meaningful if it were less ambiguous and matched to specific conditions for better measurement, just like the observational patients.

 

Hospital performance can improve with a simple change in how LOS is calculated, which would also make it a better measurement on which to base management changes.

 

Conflicting goals - There are many conflicting goals in every hospital. (The conflict between hospital reimbursement and physician reimbursement is the stuff of legend.) While the process is certainly imperfect, the simple fact is that, hospitals are paid for utilization of their assets. So, up to a certain point, inpatient LOS is a good measurement for the hospital.

 

But there is an optimum length of stay that is as unique to each hospital as its geography, service model, patient mix, charge master, and contracts. Using one standard LOS to measure hospitals across a disparate universe just makes no sense (See example below).

 

Not Normalized - In benchmarking LOS across the nation, there is shocking disparity between the different regions of the USA. Using CMS data, we compared two hospitals that are nearly identical, one in Cleveland, OH, the other in Queens, NY. Both are short-term acute-care facilities, with 250 beds, proprietary corporation control, and a case mix index of 1.25.

 

When we compared the average LOS for DRG 127, Heart Failure & Shock (CHF), a perennial high volume diagnosis, here is what we found: The Ohio hospital saw 237 cases with an average LOS of 5.16 days. The New York hospital saw 150 cases with an average LOS of 7.86 days. What explains this difference? Who cares? CHF is CHF. There is no clinical reason for treatment requiring 2.5 more days in New York than in Ohio, but there may be numerous other reasons that cannot be determined by single-mindedly looking at length of stay.

 

Good measures are relevant measures - Good measures are clear, objective, assignable and relevant. They are not open to interpretation. (An automobile is going 55 MPH or it is not.) Good measures are actionable, which means targets can be set, actions assigned, and outcomes evaluated. Good measures can be used to initiate and sustain intervention or process improvement.

 

Hospital performance measured solely or primarily by LOS is meaningless. Want a simple, easy, and very effective way to measure hospital performance? Email me. <click here>

 

 

Note: Data used is from the Medicare Hospital Market Service Area File which is updated annually by CMS. The file includes Medicare discharges, patient days, and gross charges by ZIP code for each hospital. Data are based on 100% of all Medicare fee-for-service claims during a calendar year. Go to CMS.gov for more info.

Rapid Response Teams: Too Little Too Late

The best process engineers know that designing quality into a process up front is vastly superior to correcting problems afterwards. No matter the product or service, it is always better, faster, and cheaper to start with a quality process.

This universal truth makes the notion of hospitals' "Rapid Response Teams" somewhat troubling.  While the concept of Rapid Response Teams (RRT) seems logical at first glance, it doesn't fare nearly as well under closer scrutiny. When a patient deteriorates into critical condition, the RRT brings together the best available professionals in a hospital to stabilize the patient. Sounds like a good idea, right?

Maybe not.  Although Rapid Response Teams can save lives in emergencies, there is a serious flaw in the thinking that a patient must experience some sort of critical event before this medical talent is brought to bear.  Rather than investing time and talent in creating RRT, shouldn't there be more investment in preventing the circumstances that would require an RRT in the first place?  

An industry that touts prevention needs a dose of its own medicine.  But all too often, industry incumbents who simply do not have the background or experience to design quality into day-to-day work processes dismiss using prevention as a tool for improving hospital quality.

Many would argue that RRTs are absolutely necessary and save lives. IHI justifies the need for an RRT system this way: "In the old days, a nurse could struggle for 90 minutes with a failing patient…while doing all the right things, i.e., working to assess what is going on with the patient, trying to reach the physician, waiting for test results or physician's orders, etc…. she may not actually be advancing care…."

But, an RRT does not address the underlying problem: Why is a nurse left to struggle with a patient for 90 minutes in the first place?  The RRT is only a better reaction to a seemingly self-inflicted problem.  <Read how Rapid Response Teams Improve Morale>

According to IHI, through RRTs, "Nurses are encouraged and empowered to ask for help without fear of appearing incompetent." With lives at stake, doesn't the fear of being perceived as incompetent seem misplaced?   Poor outcomes from not getting help make them look even more incompetent.

In some circles, debating the RRT concept is like debating the merits of motherhood and a hot lunch for orphans.  If they are free or easy to establish, then, of course, get an RRT in place.  Unfortunately implementing an RRT is time consuming and certainly not cheap.    <it took a $1,000,000 grant at this hospital>.  

A better debate would address the RRT's place among a larger set of hospital priorities.  The time and the money expended on an RRT might be better invested by implementing ICU physician staffing, for example. < Read fact sheet >.   In a world where less than one-third of hospitals have implemented these services, you have to wonder why there is room for an RRT. Why wouldn't a hospital invest in preventing problems instead of solving them after the fact?

Consider this: If a patient is stable enough to be admitted as an inpatient, why can't the hospital provide high quality care that would prevent the critical condition in the first place? If the best available medical team solves the problem before the patient deteriorates, it eliminates the need for an RRT in most cases – saving time, money, and lives.