How to re-engage hospitalists, rebuild care teams and improve LOS in the post-COVID environment 

Of the many disruptions resulting from the COVID-19 pandemic, one of the most serious for healthcare teams has been the disruption of communication pathways and relationships among team members. High turnover rates of locums and traveling staff, remote work and masking were all contributing factors, and at many organizations, the disrupted pathways and relationships have not yet been fully restored. 

This disruption has contributed to the increased LOS that many health systems are grappling with. Other factors are at work, including bottlenecks in discharging patients to post-acute facilities, emergency department (ED) boarding and the heightened acuity of some patients who may have delayed care. The toll is significant for organizations that cannot bring down LOS: Kaufman Hall’s National Hospital Flash Report data have indicated several correlations between managing LOS and financial performance.  

6 requirements for getting back to the basics 

Overcoming the effects of care team breakdowns that began during the COVID pandemic requires a back-to- basics approach to restore the following key components of effective care team relationships and LOS management.  

1 Multidisciplinary rounding. Multidisciplinary rounding was a casualty of the disruption of communications and relationships among care teams at organizations across the country. Multidisciplinary rounding either went away entirely or went virtual, and communications among hospitalists, nursing staff and care coordinators became less effective. 

2 Geographic staffing models for hospitalists and case management staff. When hospitalists or case managers/social workers are assigned to patients across multiple medical units, it is almost impossible for them to be consistently present for multidisciplinary rounding. Geographic staffing of hospitalists — where a high percentage of the hospitalist’s assigned patients are in the same medical unit — overcomes that barrier and builds stronger relationships among the providers in that unit. 

3 Estimated departure date as the driver of care. From the time a patient is admitted, the estimated departure date should drive decisions on the timing of needed care during the stay so the estimated departure date becomes the actual departure date. The estimated departure date should be the focus of multidisciplinary rounds, so each patient is receiving the care needed that day to move them through the care continuum. 

4 Effective utilization of advanced practice providers (APPs). Adding APPs to the care team can help observation run more efficiently and adding them to rounding teams helps improve continuity of staffing for patients, new nurses and care transitions support. 

5 Consistent communications with patients and families. Regularly updated communication boards in patient rooms help patients and their families understand the discharge process and encourage them to plan and be a part of the care transition to home. 

6 Escalation pathways to the physician adviser. Sometimes physicians need to talk to other physicians. Physician advisers act as the liaison between hospital administrators, case management and physicians. Improved collaboration is needed with the shift from fee-for-service to value-based care. The value of care is improved through physician-to-physician discussions regarding appropriate utilization of resources (treatment and testing decisions) as well as appropriate documentation for medical necessity. These conversations are critical to changing physician practice patterns. 

While these six components are the foundation of a LOS management initiative, the initiative’s success depends upon the full engagement and participation of all members of the care management team. 

What it takes to succeed 

A successful LOS management initiative begins with engagement of the hospitalists, with an understanding of their vital role in leading the care team and driving the patient’s hospital stay. It is essential that hospitalists understand the importance of geographic staffing, and of their ability to be constant and present advocates in pushing through barriers on behalf of their patients. 

Hospitalists also should be encouraged to assume a leadership role on their care teams, ensuring that rounds are timely and effective and demonstrating that making rounds is worth the time taken away from direct patient care. 

Strong nursing leadership also is an essential element of success. The nursing team should be seen as partners with the hospitalists and case managers in keeping the overall team on track and focusing everyone’s attention on key data points around each day’s plan of care and any barriers to timely discharge that must be addressed and overcome. 

As care teams are re-engaged, they must also be given the flexibility to discover what works best for the team. A particular focus here should be the format of multidisciplinary rounding, with key considerations being: 

• Who is included 

• How communications are best shared among team members 

• How accountability for actions is assigned 

A loop closure process also should be implemented to verify actions items were completed. Teams should be encouraged to try multiple iterations, with input from all team members in weekly rapid PDSA (plan-do-study-act) cycles to adjust and optimize the rounding format. 

Finally, key metrics at the floor level, hospital C-suite level and system level should be defined and monitored to prioritize initiatives that support patient throughput and enable teams to quickly act if LOS begins to rise. For example, GMLOS (geometric mean LOS) or another agreed-upon benchmark helps in reducing the impact of outlier cases and in assigning an estimated departure date. The creation of hospitalist dashboards with key metric transparency will also help drive performance and throughput. 

LOS affects so many elements of a hospital’s financial performance (e.g., volumes, revenue, margin), and it is also a key driver of patient satisfaction. By engaging hospitalists in a back-to-basics reinvigoration of care teams — supported by the staffing models and metrics required to manage LOS — hospitals can make real improvements that benefit both patient care and financial performance. 

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Case Study: The benefits of having hospitalists in charge of care team rebuilding 

A recent engagement focused on length of stay (LOS) improvement used a unique approach that puts hospitalists at the head of care team rebuilding. The engagement, involving two hospitals of approximately 600 beds each within a large health system, demonstrates the effectiveness of a back-to-basics approach. 

The hospitals were experiencing about 53,000 combined excess days at a combined annual loss of $28 million. By deploying the strategy and tactics described in this article, the hospitals: 

• Saved 6,300 days in one quarter, with an estimated savings of $5.7 million 

• Drove down the observed/expected ratio from 1.3 to 1.231 

• Improved LOS from 5.4 to 5.1  

• Improved hospitalist/provider satisfaction, with comments on enhanced communication among team members and a strengthened sense of community 

• Improved Press Ganey patient satisfaction scores within one month