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A Medical Director’s Perspective
Increased Communication, Decreased Length of Stay: The Anatomy of an
Effective Intervention
By David Reyes, MD
In December 2008, Southern Hills Medical Center’s (Southern Hills) leadership recognized an unfavorable trend in the organization’s length of
stay (LOS) metrics. The data showed that for three consecutive quarters, LOS had gradually increased. A number of issues were identified as key
contributing factors to the increased LOS, including communication between the organization’s hospitalists and case management team. The
decision was then made to implement a strategic intervention designed to improve communication, provide physicians with education on case
management’s role in the care process, and most importantly, decrease LOS.
Identifying System Issues
The need for improvement s in both LOS and communication was
identified by several members of the care team, including the
organization’s case managers, chief of medicine and director of the
hospitalists, the hospitalists, and hospital administration, including the
organization’s CFO. A meeting was held between these individuals to
determine what factors were causing the decline in performance.
This collective effort proved beneficial, as it allowed for multiple
perspectives on the issue to be shared, and revealed three key issues –
as determined by the group – which were contributing to the increase
in LOS: physician education, timing of meetings between hospitalists
and case management, and communication between hospitalists and
case management.
The Intervention
As is the case with most targeted initiatives, it is often beneficial to
research similar models, in order to build upon practices or systems
that have proven effective for other organizations. However, upon
researching interventions in place at other facilities, Southern Hills’
staff was unable to identify a model which they felt could adequately
address the specific issues and concerns identified within the
organization. At this point, the decision was made to create and
implement a specific intervention to address those key issues
contributing to the consistent increase in LOS.
Physician Education
Based on the meeting’s discussion, it became clear that the
organization’s physicians lacked a general understanding of case
management, and its role in the care process. Physicians were also
unfamiliar with the terminology commonly used by case managers, as
well as the types of reviews case managers perform on a daily basis.
To address the issue of education, a specific initiative was
employed, which was designed to raise awareness and provide
practical training in case management for the organization’s
hospitalists. The education initiative was a joint effort, led by the
organization’s case managers, as well as the chief of medicine and
director of the hospitalists.
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The main focus of the initiative was on admission and discharge
criteria used by the organization’s case managers. A general overview of
these criteria was provided, as well as a briefing on the terms involved
and the types of reviews case managers perform. This curriculum was
beneficial to the hospitalists to a certain degree; however, the
hospitalists gained a much clearer understanding of the case
management role when asked to personally perform sample reviews.
Each hospitalist involved in the intervention was assigned several
sample cases, and asked to score each case according to the criteria set.
Once each case was scored, the physicians were asked to justify their
evaluation as if presenting their case to a payor. The discharge criteria
manual followed by the organization’s case management was a critical
element of the hospitalist’s hands-on education, as it provided guidance
for each of the cases they were asked to review, and also provided
context as to the guidelines case managers are required to follow.
Providing the hospitalists with not only an overview of the key
terms and issues faced by case management, but also with an
opportunity to experience the discharge process from the case
manager’s point of view, allowed them to gain a new perspective and a
greater understanding of the case management function and the
expectations placed upon case managers.
Timing of Meetings
The next focus of the intervention was the timing of the discharge
meetings. Prior to the intervention, Southern Hill’s hospitalists and
case managers held discharge meetings every morning. Morning
meetings had proven to be counterproductive, as they occurred at a
time that was far less than opportune for both parties. Mornings are
perhaps the busiest part of a hospitalist’s day. Hospitalists work to
address all their admissions in the morning, and concurrently work to
complete all of their discharges before 11:00 a.m. Additionally, the
hospitalist is trying to see all of their established patients – who will be
staying an additional day – before 2:00 p.m., which is typically when the
Emergency Department (ED) admissions pick up. Considering all of
these responsibilities, holding a discharge meeting in the morning
proved challenging to the organization’s hospitalists.
Borrowing a concept from a hospitalist management group, an
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Increased Communication, Decreased Length of Stay: The Anatomy of an Effective Intervention
afternoon meeting time was determined to be ideal for both
parties. Based on this structure, the daily discharge meetings
were moved to 2:30 p.m.
During the meetings, case managers and hospitalists
discuss each patient’s diagnoses, discharge needs, level of
service, and barriers to discharge the following day. This focus
has allowed both case managers and hospitalists to proactively
plan for each patient’s discharge the day prior to discharge.
Communication
Communication is a key component to any successful
working relationship, and thus it is imperative to address any
communication issues as part of the intervention.
Many of the communication issues that were occurring could
largely be attributed to both parties misinterpreting what the
other was saying, and as a result, assumptions were being made
that were not healthy for the case manager-hospitalist
relationship as a whole. For example, prior to the intervention,
situations had occurred in which a hospitalist had determined
that a patient should be admitted to the hospital. Upon review,
one of the organization’s case managers argued the contrary,
stating that the patient did not meet inpatient criteria. To the
physician who is not aware that the case manager is referencing a
score card that is based upon a set of established criteria, this
objection is interpreted as the case manager challenging the
physician’s judgment as to whether or not the patient should be
in the hospital. Such instances proved to be detrimental to case
management’s credibility with the organization’s hospitalists, and
in some cases even fostered hostility between the two parties.
Such miscommunication is counter-productive to the
overall care process, and in many cases relates back to the
physician’s unfamiliarity with case management terms and
processes. For this reason, the intervention’s communication
focus was a component of the education initiative, through
which case management terms and procedures were clearly
defined. The implications of misinterpreting such terms and
procedures were also addressed in order to convey the
importance of effective communication.
Another key factor in improving the communication
between case management and the hospitalist team was case
management’s willingness to recognize that terms and concepts
that they routinely employ are foreign to most hospitalists.
Terms such as severity of illness and intensity of service are
typically not defined or discussed in medical school, residency,
or fellowship, and thus physicians often make assumptions as to
what terms such as these mean when case managers discuss
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them in practice. In this regard, case managers were encouraged
to carefully frame their interactions with hospitalists to avoid
giving the physician the impression that they are challenging the
physician’s judgment, or undermining their authority.
For instance, a case manager might relate to a hospitalist
that a particular patient does not have the intensity of service to
justify their stay in the hospital. To the physician who is
unfamiliar with this term, and is interpreting this statement
literally, the implication is that he or she, as a provider, is not
Another key factor in improving
the communication between case
management and the hospitalist team
was case management’s willingness to
recognize that terms and concepts
that they routinely employ are foreign
to most hospitalists.
doing enough for the patient, or that the treatment plans should
be modified to “play the game.” A physician would generally
resent such a statement. An alternative approach that is more
effective is for a case manager to explain to the hospitalist that
the payors, who only have access to the chart, do not possess the
same understanding as the physician who sees the patient, and
thus it is imperative that the chart clearly state certain
information in order for the payors to understand how ill the
patient is, and why they need to stay in the hospital.
Evaluating Success
To evaluate the progress of the intervention, the facility’s
providers were divided into two groups – hospitalists who had
participated in the intervention, and the non-hospitalists who
had not participated in the intervention. This structure provided
an opportunity to evaluate the intervention by examining
hospitalist LOS compared to non-hospitalist LOS.
Non-hospitalists spend most of their time in the outpatient
setting and only a small part of their time in the hospital setting.
Non-hospitalists’ system interests are primarily related to the
outpatient setting.
Hospitalists generally register a shorter LOS than non-
hospitalists. Therefore examining the difference in LOS at one
point in time would not be the most accurate measure of the
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Increased Communication, Decreased Length of Stay: The Anatomy of an Effective Intervention
intervention’s effect on LOS. For this reason, the decision was
made to examine the change in LOS for each provider group pre
and post-intervention.
From the hospitalist perspective the general assumption
was that their participation in the intervention would result in a
decreased LOS, while those who did not participate in the
intervention would experience no change in LOS.
Case managers predicted that a decrease in LOS would be
universal between both hospitalist and non-hospitalists, as case
management was participating in the intervention, and also
participating in the care of the patients being seen by the
hospitalists and non-hospitalists alike.
Evaluating the progress and success of the intervention also
presented a unique opportunity to examine whose participation
in the project was more important – the physicians’
participation, or case management’s participation.
Outcomes
Outcomes of the intervention were analyzed nine months
into the initiative. Average length of stay (ALOS) for both
hospitalists and non-hospitalists was examined by quarter for
the three quarters leading up to the intervention and the three
quarters following the intervention.
The trend in the hospitalists’ ALOS showed a progressive
increase prior to the intervention, and a gradual decrease
following the intervention; the overall decrease in ALOS being
approximately 0.5 days (see Figure A).
Although the non-hospitalists’ data showed more variability
than that of their hospitalist counterparts (consistent with this
group having more physicians, and a broader spectrum of
practice patterns), the analysis revealed the same trend of an
increase in ALOS leading up to the intervention, and a decrease
following the intervention (see Figure B).
The fact that both groups experienced a decrease in ALOS
following the intervention’s implementation can largely be
attributed to the common denominator between the two parties
– case management.
The findings supported the case managers’ hypothesis. This
finding was a powerful measure, as it further validated case
management’s importance in the care process, and clearly
illustrated their ability to influence change.
Further analyses were performed by the organization’s
decision support team to determine MSDRG-specific LOS. The
decision support team prepared data by provider group and
time period of interest and divided the physicians into four
groups to evaluate the metrics:
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• Hospitalists pre-intervention
• Hospitalists post-intervention
• Non-hospitalists pre-intervention
• Non-hospitalists post-intervention
The MSDRG-specific data also revealed a significant
decrease in LOS in both groups following the intervention.
Heart failure/shock with major co-morbidities proved to be
the MSDRG with the most significant decrease in LOS. For
hospitalists specifically, the difference in LOS in the category of
heart failure/shock with major co-morbidities between pre and
post-intervention was approximately 3.5 days reduction in LOS
(see Figure C).
Based on the results of the MSDRG analysis, there were also
some categories in which LOS increased. These categories were
in the minority, as most significantly decreased, and the increase
was minimal – typically .5 to 1 day. However, one increase in
LOS following the intervention revealed a systems issue
unrelated to the initiative.
Conclusion
The intervention implemented at Southern Hills achieved
its goals both in terms of reducing LOS and improving
communication and relationships between case management
and the hospitalists. Communication between case managers
and the physicians has greatly improved as a result of the
initiative, and physicians are now more familiar with case
management processes and terminology.
The outcomes achieved as a result of the intervention
provide solid, quantifiable proof of case management’s
influence on the care process. These outcomes also clearly
demonstrate the power of collaboration in improving rapport
amongst health care professionals, all in an effort to create a
more efficient care process.
David Reyes, MD, has been the Medical Director of Hospitalists
at Southern Hills Medical Center since 2007. He earned his
MD from Vanderbilt University in Nashville, TN. He has ten
years of experience as a physician, with over five years of
experience as a hospitalist director. He also currently serves as
Chief of Medicine and Physician Advisor to Case Management
for Southern Hills Medical Center. He recently added the
medical directorship of hospitalist program at Centennial
Medical Center to his duties.
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 C O L L A B O R A T I V E C A SE M A N A G E M EN T

Figure A Hospitalist ALOS by Quarter

Point of Intervention

5.5

5
ALOS

4.5

4
3.5
-4 -3 -2 -1 0 1 2 3 4
Quarter Relative to Intervention

Figure B Non-Hospitalist ALOS by Quarter

Point of Intervention

5.5

5
ALOS

4.5

4
3.5
-4 -3 -2 -1 0 1 2 3 4
Quarter Relative to Intervention

Figure C MS DRG MS DRG Description Absolute Change (days) Percent Change

291 Heart Fail/Shock W McC -3.5 -45%

682 Renal Failure W McC -2.2 -38%

193 Simp Pneu/ Pleu W McC -1.7 -27%

683 Renal Failure W CC -1.6 -29%

689 Kidney/Uti W McC -1.6 -30%

871 Septi/Seps Wo Mv96+Hr Wmcc -1.6 -24%

208 Resp Sys Dx W Vent <96 -1.0 -16%

641 Nutri Misc Meta Dis Wo Mc -0.8 -28%

190 Ch Obst Pulm Dis W McC -0.6 -14%

287 Circ Dis No Mi Wcath Womcc -0.6 -23%

378 Gi Hem W CC -0.4 -17%

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