KEY PERFORMANCE INDICATORS abound in health care: denial rates, collection percentages, average case mix index and many more. One of the most common metrics used to measure hospitalist performance is length of stay (LOS), which is easy to calculate and to compare to other hospitalists and organizations.
Hospitals often set LOS benchmarks using the geometric mean length of stay (GMLOS), a national mean that Medicare reports based on inpatient diagnosis related groupings (DRGs). But I would argue that it is way past time to abandon LOS as a valid performance measure.
Problems with LOS
Why? First, LOS can easily be gamed. A patient placed in observation on Monday who is then admitted on Wednesday and discharged Thursday has a length of stay of one day. Did the hospital use only one day of resources for that patient? Of course not, but that is what the data indicate.
The next time you round, do a mental check on each patient for an avoidable day.
Also, no two patients are the same. Yet using DRG 291—heart failure with a major complication or comorbidity—implies that every patient with that DRG should be discharged in 3.9 days.
But that is not how the Medicare GMLOS works; it accounts for all patients with a final DRG of 291, and the LOS distribution in that DRG goes from two days to 12. Hospitals use GMLOS because it accounts for every Medicare patient in the country and because such high volume ensures statistical significance—something no single physician or physician group can generate.
Another problem: Length of stay does not take into account the many social determinants of health that have a major impact on every aspect of a patient’s hospital course, including how long they stay. Although there are ICD-10-CM codes for these factors, they are rarely reported and none are considered a complication or comorbidity.
Many other factors that determine length of stay are likewise out of hospitalists’ control: the availability of advanced imaging on weekends, for instance, as well as OR scheduling and insurance delays.
The case for the avoidable day
Clearly, length of stay cannot accurately capture hospitalist performance. But many hospitals need some measure of efficiency to determine if beds can be opened up and patients discharged sooner. There is one measure that can improve hospital efficiency and is readily available—but all too often, it ends up in a report that no one reviews. That measure is the avoidable day.
Any day that a hospitalized patient doesn’t need hospital care is an avoidable day. While the overall number is helpful, the advantage of using the measure is that single days can usually be attributed to one of four entities: the patient (or family), the physician, the hospital or the payer.
The patient whose family heads to Florida after dropping off their loved one in the ED with altered mental status, who now has no safe discharge until the family returns? Chalk those avoidable days up to the family.
The hospital that does not do nuclear stress tests on weekends while five patients wait an extra day or two for those tests? Those days are on the hospital. The payer who takes 72 hours to approve a transfer to a skilled nursing facility but will take the referral only when the patient is ready to go is responsible for those avoidable days.
Physicians cannot do anything to prevent these. Instead, case management can staff the ED and intercede in cases that appear to be “Pop drops.” Hospital administration can assess the number of patients waiting through weekends for services available only on weekdays and decide whether to hire additional staff. The hospital contracting department can intervene with payers to change their processes and work with facilities to accept patients on an “approval pending” basis.
Days that doctors own
On the other hand, physicians who order a thyroid ultrasound and endocrinology consult for every incidental thyroid nodule on a CT scan or a sleep study for every patient whose wife claims “they make funny noises at night” absolutely can change their behavior—and reduce their patients’ length of stay. Community physicians who round in the evening and order “discharge in the morning” when patients have been stable enough for discharge all day can be counseled to adjust their practice.
Periodically, these data can be analyzed for patterns and appropriate changes made. If delays are going to be accepted, then at least the blame will go to the offending party and not always to the physician.
The next time you round, do a mental check on each patient for an avoidable day and determine to whom it would be attributed if counted. The results might not only surprise you but also lead to some needed change.
Ronald Hirsch, MD, CHCQM, CHRI, is an internist and vice president of regulations and education at R1 RCM, a physician advisory and revenue cycle company. Dr. Hirsch is also on the advisory boards of the American College of Physician Advisors and the National Association of Healthcare Revenue Integrity, and he is the coauthor of “The Hospital Guide to Contemporary Utilization Review.”
Published in the March/April 2023 issue of Today’s Hospitalist
