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On May 10, 2018, Brian commented on Medication reconciliation :

Our organization is working on a project around this now. Our issues have been the same as others have articulated- inconsistent process completed by a myriad of staff types. We are in the process of dedicating a team that has the sole function of completing medication reconciliations for all inpatients. As an admit to inpatient order is entered into the EMR, the med reconciliation team will receive an alert, which triggers their review. To justify the project (beyond improved patient care), we reviewed published literature and internal cases where medication errors occurred, and looked at the added cost to the system due to medication errors. We found that correcting the errors, and eliminating excess costs due to errors, far outweighs the expense of the medication reconciliation team.

On May 8, 2018, Brian commented on Absenteeism :

Despite the financial challenges, you may still want to consider a time and attendance bonus, especially ion the union side. Does not need to be a significant amount of money, but enough to make improved attendance enticing. With high absenteeism, my guess is you are incurring significant costs or lost revenue- premium pay/OT for replacing lost shifts, or the inability to perform cases, accept patients, etc. without adequate staffing. If you were to implement the program now, you wouldn’t incur the expense of bonus payout for say 6 months to a year. This gives plenty of time to garner more than enough savings/revenue to offset the bonus expense, and achieve a return.

Can’t speak to how it will work yet, but this is a project we are working on. We have found that, by and large, when our clinic patients come to the emergency department for lower level concerns, they generally present between normal clinic hours. We are working on introducing an ED Diversion program whereby through signage and the registration process, clinic patients will be made aware of their option to utilize the ED diversion program in lieu of the ED. To support the program, we will be putting a concierge in the ED to assist the patient in getting from the ED to the ED diversion program (should they choose), and augmenting our clinic staff with an additional APP to cover this volume. The intent is to have patients self-select as candidates rather than be identified through triage/evaluation. Our concern is that patients may learn that this is an easier and quicker way to get in for a clinic appointment, bypassing scheduling.

On May 1, 2018, Brian commented on Increasing Length of Stay :

Our organization has had some success in reducing LOS over the past few years, and it has led to significant cost reductions at our hospitals. The most important piece of moving LOS is being vigilant, understanding the drivers, and having senior leadership engaged. When we started the process, our utilization management team would connect with our COO every morning to review the overnight change in LOS- if there was an uptick, was it due to an outlier patient being discharged, or was it more of an overall throughput issue? Here are some strategies we used:
• Push LOS data out to physicians on a monthly basis so they can see their numbers. As possible, compare to an applicable benchmark (we use Crimson).
• Engage physician leaders for each service line (or at least the high volume ones) that can own or at least help drive LOS for their service line.
• Look at the % of patients that are discharged before 11AM, and set a loftier target. This will free up beds for afternoon/evening admissions.
• Resource environmental services to when most of the discharges are occurring. Longer waits to be bedded from the ED will lead to longer LOS.
• Review the time between when a discharge order is written and when the patient physically leaves, and identify improvement opportunities. We isolated by nursing unit and found significant variance between units.
• Review time that the discharge order is written trends by physician, and look for opportunities for earlier orders.
• Look for trends- by service line, by disposition, by physician, etc. We found that we got patients out quickly when they were going home, but were experiencing delays for patients going to SNF or Home Health. We worked on identifying patients that needed these services earlier in the stay, getting screeners in earlier, working on quicker insurance authorizations, as strategies. We reviewed results with key stakeholders monthly.
• Hold a weekly outlier meeting. Our sites have a multidisciplinary team review all inhouse cases with LOS of 20 days or greater, and review and address barriers to discharge.
• For surgical patients, look at how long the patient is inhouse before the procedure. We found, especially in cardiac, that surgeons were bringing patient in for days in advance of the procedure unnecessarily.
• Ensure adequate resourcing of discharge planning over the weekend. We found that many patients were staying unnecessarily not for medical necessity, but due to discharge planning resources.
• Send the message that discharge planning starts on the day of admission, not when the patient is close to being ready to go home.
• Set the expectation with the patient- let them know that typical stays for their condition are X days. This helps them to arrange transportation resources in advance.

Our organization has implemented gainsharing programs for inpatient commercial and CMS BPCI (bundled payment) cases. The program incentivizes attending/operating physicians based upon quality and cost metrics. In order to qualify for an incentive, the physician needs to pass quality metrics first- regardless of how efficient the physician is on the cost side, they are ineligible for payouts without achieving quality standards. Assuming the physician passes quality, their cost efficiencies determine the payout. For our larger gainsharing program, we look at the standard deviation of the physician’s direct costs compared to national benchmarks in similar hospital types to measure efficiency. Benchmarks are grounded in same DRG, severity and patient age. The bundled payment program is similar, though cost comparisons are for a 90 day episode of care (rather than just the inpatient stay), and are tracked against a DRG only based benchmark that is based upon our organization’s historical performance. Each program has limitations/caps on what can be earned, based on the premise that we look to incentivize efficiency and not a reduction in care.