Ensuring Quality, Efficient Care by Reducing Length of Stay

Our progress in reducing inpatient length of stay is proof of what is possible when we are united in our efforts to improve outcomes for our patients.

Focusing on the delivery of efficient care that improves the overall quality of the care we provide, our Quality and Patient Care Progression strategies are equipping frontline care teams with the data and tools they need to reduce length of stay.

“Length of stay is a tremendously important but often-overlooked quality measure,” said Rachel Sisodia, MD, chief quality officer for Mass General Brigham (MGB). “Shorter length of stay means patients are recovering faster, minimizing the adverse events associated with hospitalization and improving access for our many patients who require care in our inpatient units.”

The adverse events are well documented in clinical studies. Prolonged hospital stays increase patients’ exposure to delirium and hospital-acquired infections. They also have negative downstream effects on patients boarding in the Emergency Department, waiting for an inpatient bed. Longer boarding times are associated with increased mortality. 

To reduce risks and improve outcomes, we made efficiency — measured by length of stay — one of five main focus areas of our For Every Patient unified quality strategy. We are bringing this strategy to our patients through our transformation into a High Reliability Organization (HRO), which seeks to foster a culture where everyone is accountable for quality, and the adoption of HRO unit-based quality rounds by our frontline care teams. 

“Rounds are empowering our clinicians to improve quality,” said Jenn Vazza, MCSO, vice president of Clinical Performance for MGB. “They foster open communication among our clinical providers on a unit that encourages collaboration and proactive problem-solving.” 

Care teams on units where rounds have been implemented are using near real-time, unit-specific data around key quality domains (Effectiveness, Safety, Efficiency, Experience, Equity) and associated metrics, including length of stay, to develop and implement process improvements that are benefiting patients and improving quality. 

Led within each department by our chairs and other clinical leaders, efforts to reduce length of stay are bolstered by support from multidisciplinary teams working on our Patient Care Progression initiative, which is focused on eliminating systemic barriers that slow the medical progression of patients’ recovery and prevent timely transitions out of the hospital. This support includes providing weekly length-of-stay data and benchmarks, as well as a “tool kit” of best practices to help reduce length of stay.

“Quality rounds have provided an invaluable opportunity to engage with units on length of stay, listen to their needs and challenges, support their ideas and solutions and provide them with resources,” said Kyan Safavi, MD, MBA, senior medical director of Clinical Integration and Operations for MGB. Safavi is coordinating our Patient Care Progression work along with Vice President of Operations Niki Keefe, RN, MSN, MBA.

Quality rounds have been rolled out across 16 units at our academic medical centers. They recently launched on three Salem Hospital units and are launching today on three Newton-Wellesley Hospital units as well. Rounds will eventually be adopted systemwide.

Held every other week, rounds bring together frontline clinicians and staff with hospital and system leaders to review a unit’s own data, which is displayed on a “scorecard” that tracks risks across a series of metrics that are key to improving patient outcomes, experience, equity and the overall care we provide. 

During these huddles, staff can identify challenges related to patient progression, share ideas for improvement and then help operationalize proposed solutions.

For general care units, Patient Care Progression uses a unit’s discharge rate to measure length of stay. A validated metric that has been implemented successfully at MGB and other health systems, the rate correlates closely with length of stay.

“The data provide transparency that is helping our care teams identify risk and work together on solutions to improve outcomes for our patients,” Vazza said. “Ideally, quality rounds will become an incubator for the best new ideas and practices, like the improvement initiative on Blake 8, that could eventually be spread systemwide.”

A great outcome

On Blake 8, a Cardiac Surgical ICU at Massachusetts General Hospital (MGH), rounds sparked a collaboration between the unit’s physicians, advanced practice providers and nurses who together focused on eliminating delays in transferring patients to step-down units.

The teams established nightly, cross-team communication to help identify and prepare patients who were ready to have chest tubes and wires removed. Eligible patients are now ready for transfer by 10 a.m. each day. As a result, Blake 8’s length-of-stay performance improved from 1.6 days to .9 days (target is 1 day) within three months, highlighting the success of the unit’s multidisciplinary intervention.

“Rounds are bringing the unit together as a team,” said Megan Tibbetts, CNP, who is leading the improvement initiative in collaboration with unit Medical Director Aranya Bagchi, MBBS, and Nursing Director Vivian Donahue, RN. “Colleagues in every role are invested in improving outcomes for our patients, and it’s great to see we’re making an impact.”

Equipping teams with the tools they need

Every unit participating in quality rounds receives a tool kit of resources for each role group (provider, nurse and case manager) that can be used to support patient progression.

Nurses, for example, receive tip sheets on the assessment and management of delirium and mobility. These tools, designed by our system’s nursing leaders, guide staff on how to use nationally validated methodologies to support delirium care and increase patient mobility.

Mobility guidance was developed by nursing and physical therapy leaders, incorporating best practices already in place at our community hospitals. It includes a validated mobility assessment tool that assigns patients a mobility score on admission. The score improves early identification of post-acute care needs and reduces unnecessary physical therapy consults, which can further prolong care.

“We are using data to predict what patients’ needs will be and initiate earlier Case Management involvement to assist with care transitions,” said Debra Burke, RN, DNP, MBA, NEA-BC, senior vice president of Patient Care Services and chief nursing officer at MGH.

“We are creating a culture where everyone who is taking care of patients is thinking about mobility,” said Reg B. Wilcox III, PT, DPT, MS, MBA, OCS, executive director of Rehabilitation at Brigham and Women’s Hospital and Brigham and Women’s Faulkner Hospital. “Mobility scoring by our nurses is an important step in that process.”

“Quality rounds provide a powerful opportunity for continual learning, collaboration and improvement,” Safavi said. “That’s what is so exciting about becoming a High Reliability Organization.”