CC
QI Spotlight: Reducing the Length of Stay in Acute Inpatient Rehab
This month our QI Project Spotlight was submitted by Robert Holland, MD.
In 2017 Dr. Holland earned a master’s in health care administration from Columbia University’s Mailman School of Public Health. He is currently the Catherine and Vladislav P. Hinterbuchner Professor and Chair at New York Medical College, the Chief of Rehabilitation Medicine at Metropolitan Hospital and the Residency Program Director for PM&R (based at Metropolitan). He is also a flight surgeon with the New York State Air National Guard 105th Medical Group.
"I would like to credit these leadership experiences with helping to design this and other QI projects. In this case we wanted to reduce our length of stay to help with patient throughput through the hospital (my rehab is hospital-based rather than free-standing). We serve a vulnerable population of patients that often have insecure discharge dispositions, so the hypothesis was that by involving the family at an early stage and marshalling those resources we could avoid longer stays. Seems like it’s working!" - Dr. Holland
Thank you for submitting your project, Dr. Holland!
The QI Project Spotlight is a periodic feature on the ABPMR News Center to highlight exemplary Quality Improvement projects submitted by your fellow diplomates (or residents) for continuing certification (CC) credit. Diplomates can use the QI Project Spotlight as a tool to plan their own QIs or as a way to connect with other diplomates doing similar work.
What is the problem you are trying to solve?
Reducing the length of stay (LOS) for admissions to the acute inpatient rehab unit. As a 20-bed, hospital-based acute rehabilitation unit, we sought to reduce LOS to help with patient throughput through the hospital system and identified the SMART (Specific, Measurable, Achievable, Realistic & Timebound) goal of reducing length of stay on the inpatient unit from 14.8 days in 2023 to at or below the Regional average of 14.1 days (as defined by CMS) by December 2024.
What data (objective measurements) do you have that supports this as a problem?
Average length of stay of 14.8 days per rehab admission was identified for 2023. Quarter 1 length of stay data for 2024 was identified at 14.3 days. April 2024 LOS was 14.1 days. The QAPI project was implemented in May 2024.
What is your opportunity statement? State the goal you hope to achieve.
As a 20-bed, hospital-based acute rehabilitation unit, we sought to reduce LOS to help with patient throughput through the hospital system and identified the SMART (Specific, Measurable, Achievable, Realistic & Timebound) goal of reducing length of stay on the inpatient unit from 14.8 days in 2023 to at or below the Regional average of 14.1 days (as defined by CMS) by December 2024 (a period of 7 months.) Many of our patients are underprivileged or otherwise vulnerable, and lack of resources often created a barrier to discharge, extending the length of stay. For our Process measure, we hypothesized that identifying the need for a family meeting early in the rehab stay (at the first IDT meeting) and conducting that meeting to bring family into the discharge planning process would help to reduce LOS (LOS being our Outcome measure.)
What is the underlying cause of the performance/quality problem?
Many of our patients are underprivileged or otherwise vulnerable, and lack of resources often created a barrier to discharge, extending the length of stay. Metropolitan Hospital also accepts a large percentage of "self-pay" or charity cases to acute inpatient rehabilitation as our mission is to care for everyone regardless of ability to pay. This can create a challenge at discharge, however, as without a payor source home services can be difficult or impossible to implement and subacute placement is unlikely.
What change(s) did you implement?
For our Process measure, we hypothesized that identifying the need for a family meeting early in the rehab stay (at the first IDT meeting) and conducting that meeting to bring family into the discharge planning process would help to reduce LOS (LOS being our Outcome measure.) We then monitored the percentage per month of recommended family meetings to those that actually took place and reported this percentage as the Process measure (numerator = # of family meetings per month which actually occurred / denominator = # of family meetings per month identified as needed for discharge planning). This was compared to our monthly LOS (our Process measure). Our Balance measure (unforeseen consequences of our QAPI) was to monitor for an increase in 30 day readmissions after discharge, which would signal that by reducing the length of stay patients were perhaps less medically stable at time of discharge or less functionally able to care for themselves at home resulting in readmission to the hospital. We have seen no increase in 30 day readmissions for the duration of the QAPI to date. We also used an Equity Lens to look at length of stay for both insured and "self-pay" patients and found no significant difference in the length of stay rates for these two cohorts.
Did you achieve your goal or target from your opportunity statement? What data do you have to support your conclusion?
We achieved our goal of reducing length of stay to below the regional average by August 2024, when we realized a LOS of 12.7 days (vs 14.1 regional average and 14.8 for the facility in 2023). This correlated with an increase in family meetings identified early in the rehab stay and conducted prior to discharge.
Month Avg LOS (days) % Family Meetings conducted % patients readmitted within 30 days:
April 2024 14.1 n/a n/a
May 2024 13.8 71% 0%
June 2024 13.8 100% 4.1%
July 2024 14 33% 0%
August 2024 12.7 57% 0%
How will you maintain the success of your project going forward?
Having met the project goal, I had the opportunity to present this QAPI project to the Board of Directors for NYC Health + Hospitals and have the full support of Leadership to continue the project. Stakeholder buy-in from the IDT is high, so barriers to continuation of the project are low. We will continue to identify family meetings, track the % of meetings that occur, and correlate this data with our length of stay. We will also continue to monitor our balance measure and equity lens to ensure the we do not inadvertently increase 30 day readmissions while reducing our LOS and that all patients are treated equally (e.g. have equal length of stays) regardless of payor source. I would also value the opportunity to submit my PowerPoint presentation for your review to supplement this submission.
I am honored to be selected for the QI spotlight feature. The team at Metropolitan worked hard on the project and it was great to share this news with everyone.
