Improving Length of Stay at San Antonio Community Hospital

During most of the latter half of the 20th century, hospitals were rewarded for each day that a patient was in the hospital. However, during the 1980s and 1990s, governments’ systems began to evolve to payment by diagnosis (DRG in the US, similar to HRG). This placed increasing pressure on hospitals to reduce costs through reducing the length of inpatient stays, while maintaining or improving quality.

The Challenge

The San Antonio Community Hospital is a 300-bed not-for-profit acute care hospital in Southern California, USA, with $275M net revenue p.a. and 1800 employees. They lost $8M two years in a row. Approximately 50% of the hospital admissions involved Medicare patients for whom the hospital received a fixed DRG-based payment. During that period of time, the average length of stay (ALOS) for Medicare patients increased from 5.6 days to 6.2 days, costing the hospital millions of dollars. Subsequently, the ALOS for the next year had increased to 6.7 days, further deepening the financial crisis at the hospital.

The Solution

Aggressive actions were needed to reduce ALOS and improve quality of care at this facility. A physician/nurse team was deployed to use a RealTime-based approach to work with the case management staff and physicians to decrease Average Length of Stay (ALOS) and improve care for patients.

The RealTime methodology reduces ALOS by enabling the discharge process to be clinically driven and collaboratively managed using an evidence-based approach measured continually against agreed key performance indicators (KPIs).

The RealTime clinical process change methodology focuses first on reducing LOS for the over-65s with the top 25-30 HRGs, as this will rapidly free up bed-days and enable improvements elsewhere (the committed goal of any RealTime-based project in the first 12 months = at least 5% reduction in LOS, subject to more detailed analysis, and possibly greater). The methodology encompasses a number of key phases: assessment, planning and implementation. During the assessment phase, existing discharge planning and bed management processes are evaluated through observation; interviews with staff, consultants and management; and review of documented policies and procedures, reports and medical records. This culminates in a defined set of recommendations for improvement.

The planning phase consists of design of new workflows to address gaps between existing and desired processes that have been identified during the assessment phase, identification of internal resources, selection of rollout wards, establishment of new LOS targets for the top 25-30 HRGs, outlining of a communications plan and development of a joint implementation plan. The implementation phase begins with application of the work plan, along with careful monitoring and tracking.

The Benefits include:

• More patients are treated, and patients are treated more quickly;
• Safety, from better assurance and communications in the care and discharge planning process;
• Emergency Preparedness, with improved knowledge and control of bed occupancy and the ability to discharge;
• Correct location, leading to reduced risk to the patient and saved clinical time;
• Closer match between ED waiting times and clinical need.

The Results:

• Measurements of key quality performance criteria for pneumonia, heart failure and heart attack improved by a minimum of 20%;
• Both readmission rates and mortality rates for key diagnoses decreased;
• Today, the hospital is taking advantage of the $25M in cumulative savings and investing in new equipment and facilities improvements.

The performance improvement is shown thus:

 

In the words of Roger Parsons, Chief Financial Officer of San Antonio Community Hospital, "The length of stay reduction project is the most successful project we have ever had. It is the best example of continuous improvement I have ever seen. We reduced our ALOS for Medicare by 30% and saved $10-15M annually."