VA hospitals overhaul discharge planning to cut average LOS
CQI techniques enabled facilities to make fast turnarounds
This is the tale of two Veteran Administration hospitals in two cities on two coasts but with one set of very serious problems. While Boston VA Medical Center is a continent away from its sister facility, West Los Angeles (CA) VA Medical Center, it had in common a culture that has always put a premium on patient care, while being notoriously inefficient in delivering that care.
Today, the Boston VA is recognized for its centers of excellence, and the West Los Angeles VA has won the Carey Award, the VA system’s highest quality award. Figuratively speaking, both turned the quality corner about two years ago, when quality managers, acting on marching orders from headquarters in Washington, DC, sought to make their institutions’ quality record comparable to any found in either the public or private sector.
Unfortunately, the managers were up against some big obstacles. At both hospital systems, a lack of case management and discharge planning had length of stays (LOS) out of control, while outpatient and home care services were woefully underutilized. Here’s how the two hospitals solved their problems and what they learned.
Not the best of times
Boston VA Medical Center began the road to improvement after quality managers assessed its admitting procedures and realized it lacked a coordinated discharge planning process. The hospital also did not have a case management model, and patients were often admitted without a treatment plan.
"We were using such archaic methods in our facility, just going along doing things like we always had always done," says Deborah F. Creech, RN, BAN, MSM, director of quality management. "Our average length of stay was about 12 days for both our medical and surgical wards, which was grossly higher than the average."
Even though a systemwide total quality management program was mandated by VA headquarters about five years ago, Boston VA had not "institutionalized" TQM, says Creech. Even as late as two years ago, Boston VA would admit patients and then decide what to do with them, she says, despite an awareness that this approach would not meet current quality standards.
"Even if someone may not have been appropriate for admission, we would have to admit him or her because Congress set [the guidelines]," she explains. "But it wasn’t until the VA started pushing for changes and making the closer comparison with the private sector that we realized how outdated we really were."
About 18 months ago, a CQI team on discharge planning was created to solve the LOS problem, but it had barely gotten started before all involved realized that a big piece of the solution would be to implement some type of case management. Composed of physician leaders, nurses, and representatives from social services, pharmacy, unit coordination, admissions and billing, the team decided the first task would be to benchmark care models.
Toward that end, the team did telephone surveys and site visits with several other VA and private hospitals, but it was the care model the team found at Deaconess Hospital, also in Boston, that would be adapted for Boston VA. That model was the social worker/nurse case management team.
To implement the model at Boston VA, a new CQI case management team was formed. On it were many of the same types of people as on the discharge planning team, plus nurse reviewers and inpatient social workers. The team started a six-month test of its own model in January, but within three months, physicians and nurses liked the pilot so much it was adopted permanently. The hospital’s previous care model had been a team approach that received high marks from patients on satisfaction surveys but left staff frustrated about duplication of effort and wasted time, says Creech.
While the discharge and case management improvements got under way, TQM efforts were gaining momentum elsewhere at Boston VA. Eventually, a Primary Care Coordinating Group, composed of physician leaders, managers from the women’s health center, the hospital’s ambulatory/diagnostic treatment centers, administration executives, nurse executives, and practitioners, evolved to oversee the other quality groups.
They tap into other teams when necessary, explains Creech. For example, the coordinating group works closely with CQI teams overseeing the hospital’s transition from manual to electronic medical records. To help guide these quality efforts, Boston VA contracts with a peer review company, West Virginia Medical Institute Inc. (WVMI) in Charleston. WVMI facilitates benchmarking within the national VA hospital system and against other national indicators.
"By [benchmarking], we could say we’re below the average here and here, or we are doing surprisingly well over here. Before we didn’t have much to go on," says Maureen Monroy, continuous quality coordinator at Boston VA. "We all had to get into a completely different mindset and had to rework a lot of our systems. The teams created the support structure we needed to make core changes in how we do business."
Each month, WVMI visits Boston VA and reviews a percentage of cases and measures them against other VA hospitals in several categories: disease prevention and the management of chronic diseases; screening for disease prevention, such as tobacco use, and prostate, cervical and breast cancer; and end of life planning for patients with terminal illnesses.
"When the VA headquarters contracted us with the West Virginia Medical Institute, we found we were rating extremely well in all areas except disease prevention, and that really surprised us," notes Creech. In particular, WVMI found two weaknesses:
1. underutilization of screening, such as for prostate, breast, and uterine cancers;
2. documenting by exception in primary care, which left an incomplete picture of exactly what treatment was provided in most cases.
To remedy these deficiencies, the quality team took two steps. First, it coordinated with the information services team to make sure the electronic record included what Creech calls "patient care encounters." These took the form of a primary care template that was embedded in the software program. The template tells the caregivers what needs to be done for each type of patient. Second, the team set up triggers within the software program to prompt caregivers regarding such things as vaccines or the need to counsel a patient on cholesterol control. (See template, p. 151, and triggers, at left.)
Of course, implementation of case management and discharge planning put greater demands on the hospital’s ambulatory and home care services. "We had preadmission testing and screening, but it was largely unused," says Creech. Before the improvement efforts, Boston VA was doing only about 30% of the procedures HCFA recommends be done in an outpatient setting, she says. Over the past year, that percentage has grown to nearly 80%.
As case management shifted demand more to home care, the coordinating group spearheaded improvements there, as well. Disjointed efforts were melded into a physician-headed team approach. At weekly team meetings, the physician coordinates with other caregivers, such as respiratory therapists and social workers, on the patient’s care regimen.
Together, these improvements have reduced LOS about one-third, from 12 days to less than eight. "That’s a huge improvement, but it’s still not where we want to be," says Monroy. "We’ll continue working on ways to cut it even more." The shift in resources has also meant that Boston VA has reduced its operating beds from 400+ to about 280. Creech has not done any financial analysis of the savings these improvements have wrought, although she is sure big savings are there. With barely a year gone by and the transition into electronic records incomplete, she wants to perfect the new processes before subjecting them to formal financial analysis, she says.
Another winter of despair
When a major earthquake rocked southern California in 1994, West Los Angeles Veterans Affairs Medical Center was inundated with patients from its sister facility, Sepulveda VA Medical Center, which was destroyed by the quake. It was a rude awakening for the nation’s largest VA medical center.
"We had been exposed to quality improvement philosophies a few years earlier when the VA system started its nationwide performance improvement [push], but we hadn’t really operationalized it yet. But you sometimes don’t realize what changes need to be made until something drastic happens," recalls James Bobinyec, MPA, executive assistant for total quality assurance at West Los Angeles VA.
The emergency made it clear that some long-standing problems could no longer be ignored. "We weren’t ready when the [earthquake hit]," says Bobinyec, "but we couldn’t blame it on the number of patients. We had a process problem, not a people problem. But when it was over, we knew where our weaknesses were and that they would have to be improved in order to provide better care in the future." Those weaknesses included a lack of solid discharge planning and an excessive preoperative LOS 5.1 days. The lengthy stays prevented other patients from being admitted and treated in a timely manner a problem that can mean life or death when disasters strike and many patients require immediate attention. To make matters worse, nonemergency patients piled into ambulatory care areas, which further delayed the treatment of needier patients.
The first step in the hospital’s improvement process was developing multidisciplinary discharge planning teams. Fourteen staffers from social work, medicine, geriatric care, medical administration, nursing, and quality management comprised the team. Using a hospitalwide quality improvement model Understand, Analyze, and Improve the group then began flowcharting the discharge planning process and making necessary changes.
"When we finished flowcharting the process, we came up with a fishbone diagram based on [the results]," Bobinyec notes. "There were so many problems in the system that when we put the diagram up on the wall; it took up almost the entire wall. But we could see exactly where the process got backed up and where we needed to go."
One major discharge glitch uncovered was one of the easiest to fix. When homeless patients were admitted, the floor supervisor would place their belongings in a locked storage area. That system worked well as long as the patient wasn’t discharged on a Friday evening after the supervisor in charge of the belongings had already left for the weekend.
"That meant we couldn’t get bags out of storage until the following Monday if [a patient] was discharged on the weekend," Bobinyec says. "We have a pretty big homeless population, so those bags are all that person has. And if they couldn’t get their bags, we would have to keep them another couple of days."
To prevent these unnecessary hospital stays, the hospital handed the storage responsibility and the keys over to its environmental services personnel.
"There’s someone from housekeeping in [the hospital] 24 hours a day, so we eliminated the problem entirely. It was a simple change, but it made a difference," he adds.
Like Boston VA, inefficient preoperative checkup procedures also increased LOS. Patients were admitted two to three days before surgery for lab work and other routine tests to prevent surgery cancellations. "If a patient didn’t come in early, the tests sometimes wouldn’t be ready in time and the surgery would have to be cancelled," notes Bobinyec. "If the patient was in the hospital, we could make sure the tests were done in time, but it was also increasing our LOS and costing a lot of money in the process."
By late 1995, quality teams were at work on West Los Angeles VA’s preoperative clinics and ambulatory surgery sites. They set up a system that makes an appointment for each patient with the pre-op clinic as soon as the doctor determines if surgery is required. Patients requiring only minor surgery can now be treated in ambulatory surgery centers and bypass the hospital altogether.
Because of the changes, average preoperative LOS fell from 5.1 days in 1995 to just 0.6 days in 1997. Surgery cancellation rates also tumbled from 30% in 1995 to about 9% in 1997, while the number of surgeries performed in outpatient clinics grew from 56% in 1995 to 75% in June 1997. (See chart, p. 153.)
The best of times
"We’re moving toward a primary care model like other hospitals, and that’s a big change for VA organizations that never did business this way before," says Bobinyec. " We’re still in the beginning stages, but we’re already strengthening our care across the continuum."
These improvements have helped the hospital slash the number of inpatient beds by almost 60%. In 1996, the number of inpatient beds totaled 1,202. By 1997, that number fell to 503. The excess beds were donated to the Salvation Army’s homeless program, which runs a shelter adjacent to the hospital.
"We started a community support program with the Salvation Army to strengthen the continuum of care in our homeless population," notes Bobinyec. "These people don’t have homes that they can go to when they are released from the hospital, so we give them a place where they can still be looked after and treated, if necessary."
The hospital’s accomplishments in September won West Los Angeles VA the Robert W. Carey Quality Award, the VA’s highest quality award. The annual award, which follows the Malcolm Baldrige Quality Award criteria, recognizes Department of Veterans Affairs organizations that strive and excel in quality achievement.
"When you look at what we’re doing now compared to what we were doing just a few years ago, you wouldn’t believe it," notes Bobinyec. "It’s wonderful to win the award and see the results, but this is an ongoing process for us now. Even though we’re different from [private sector] hospitals in many ways, we also have to be moving in similar directions. The VA system needs to be a major player in the health care industry," he adds. "And it looks like we’re already on our way."
[For more information, contact Deborah Creech, Boston VA Medical Center, 150 South Huntington Ave., Boston, MA 02130-4893. Telephone: (617) 232-9500. Or contact James Bobinyec, West Los Angeles VA Medical Center, 11301 Wilshire Blvd., Los Angeles, CA 90073. Telephone: (310) 478-3711.]
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content