Hospital cuts LOS in half for CHF patients
Process approach attacks hidden costs
Case managers at Rowan Regional Medical Center in Salisbury, NC, took a unique approach in developing the center’s clinical pathway for congestive heart failure (CHF). By addressing the underlying issues that affect costs and length of stay (LOS), they managed to achieve a 50% drop in LOS just three months after implementing the path. (See chart on trends in LOS, below.)
When the pathway was introduced in fall 1994, the average LOS was 7.4 days, while charges averaged $5,100 per patient. By the first quarter of 1995, LOS had fallen to 3.7 days, where it remains, and charges had dropped to $3,600. (While the center won’t release data on costs per case, it maintains that its reimbursements exceed its costs for CHF.)
LaVaughn Beaver, RN, CPHQ, ABQAURP, utilization review and quality management supervisor at Rowan Regional, attributes the sharp and sudden drop in LOS to the center’s "process approach" to pathway development. "By the time we get ready to use a pathway, a lot of the changes have already been made," she says. "We don’t just write the pathway down, hand out copies and say Here, do it.’ We actually change processes as we go, so that by the time we get ready to implement a pathway, a lot of the things that were causing longer lengths of stay, higher charges, and not as good quality of care have already been improved."
CHF was selected to be Rowan’s first pathway because of its high volume and the wide variety in physician practice patterns identified by the center’s utilization reviewers. "One thing we identified up front before we started any pathways was that one definition of quality was to decrease variation," Beaver says. "A pathway should define the best practice pattern of taking care of the patient. So by doing that and changing some processes as we went, we decreased some variation."
In developing a pathway and analyzing variations in physician practice patterns, Beaver stresses the importance of getting severity-adjusted data. "What used to happen before we had severity-adjusted data, is that a doctor would always claim his patient was sicker," Beaver says. "That may be, but with severity adjustment, it takes that component out of the comparison data, so you can compare apples to apples." For its severity-adjusted data, Rowan contracts with Iameter, a San Mateo, CA-based consulting firm that produces software for benchmarking and quality improvement.
So important are the process changes identified during pathway development that Beaver contends, "By the time we get ready to implement the pathway, we could probably tear it up and throw it away and not even have a piece of paper." Indeed, she notes that the pathway itself is fairly plain. "It doesn’t go into a lot of detail. But that’s because a lot of things are changed during the development of the path."
One process improvement identified during the development process concerned the lack of pulse oximeters on the nursing units. Whenever a patient required a pulse oximeter, a nurse had to contact respiratory therapy, who would then visit the unit and check the patient’s oxygen level. By making the machines available on all nursing units, nurses are able to take readings with their morning rounds and convey the results to the physicians. "Because nurses didn’t have to wait and get an order and then wait on respiratory therapy, it speeded up the process," Beaver says.
Other process improvements identified for CHF patients include the following:
• less IV fluid use;
• increased IV lock use;
• improved admission and daily weight recordings to help quantitate diuresis;
• development of a process for documenting which scales were used, and using same scales for patients when possible;
• calibration of scales;
• earlier discontinuance of nasal O2;
• earlier ambulation;
• reporting of cost accounting to departments of internal medicine and family practice;
• evaluation and refinement of occurrence screens for data collection;
• use of PRO discharge quality indicator screens.
The focus on identifying improvements has had the added benefit of encouraging physician and staff support for the pathway, Beaver says. "We encourage very large multidisciplinary and interdisciplinary approaches, and we have very good physician buy-in to our program. Our way of doing it creates more of a sense of ownership from all the different disciplines."
During the pathway development process, the pathway team establishes department-specific focus groups to elicit suggestions on possible improvements. "Like with nursing," Beaver says. "Someone in nursing probably had an idea of how to improve something a long time before it ever surfaced. But they didn’t know the right place to tell it or where to get attention with their ideas. So the pathway groups create an avenue for people to voice their opinions."
Similarly, changes to the pathway are usually made at the suggestion of someone in the affected area. "For instance, if there were to be a change in radiology, that’s probably where [the idea] would originate," Beaver says. "Then we would take it back to our whole group." In addition to such periodic changes, the pathway is reviewed on a yearly basis.
Although Rowan continues to develop pathways for other patient populations, Beaver concedes that the development process there is slow. "But that’s because of the method we’ve chosen to do our pathways," she says. "When you make a change for one pathway, it has a sort of cascade effect on all the patients in the hospital."
For more information about the CHF pathway, contact the following:
LaVaughn Beaver, RN, CPHQ, ABQAURP, utilization review and quality management supervisor, Rowan Regional Medical Center, 612 Moncksville Ave., Salisbury, NC 28144. Telephone: (704) 638-1000.
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