Small Changes Can Make a Big Difference

small steps

In today’s healthcare environment, we often think that all operational changes have to be major and transformative. In order to gain improvements, we have to gather an interdisciplinary team, undergo days of process maps and education of staff. Indeed, those tasks are required for major advancements. But sometimes we lose sight of what can be gained with small changes. With small adjustments to our current processes, we can see incremental improvements for patients and our financial status at very low risk and minimal cost.

I recently worked with a client in which we were able to make some of these small changes that made a big difference. The first related to ICU capacity. The hospital frequently went on diversion due to overcrowding in their 32 bed MICU. The publication Emergency Physicians Monthly has conducted an analysis to calculate direct impact of diversions to the bottom line. The analysis indicated that an admitted patient contributes an average of $6,000 above the direct cost of service to the bottom line. Statistics show that more than 40% of patients brought to the ED by ambulance are admitted as inpatients. If that is the case, every 10 patients diverted costs the hospital 4 admissions, or $24,000.1

In their current practice, the MICU was open to all physicians for admission, and politics prevented changing to a closed unit in the near future. Physicians often stated that they wanted the patient to stay “just one more night” to insure that they were ready to move out of the unit to a lower level of care. At the same time, the patients no longer met criteria of needing a critical care bed.

We put together a small team comprised of the charge nurse, case manager, social worker and Care Management physician advisor. They meet every Monday, Wednesday and Friday morning, and other mornings if needed, to identify patients that could be transferred to a lower level of care. The nurses would then reach out to the physicians asking for transfer orders. When they met resistance, the Physician Advisor would step in and talk with the Attending Physician. It helped that the Physician Advisor was a retired surgeon and had the respect of the medical staff. The result: they were able to free up beds for ED patients, allowing those patients and their families to remain in their community rather than being transferred to the nearest hospital 50 miles away.

The second change related to patients waiting for court appointed guardianships. This hospital, at any time, had 3-7 patients waiting for guardianship appointments. The average time to get a guardianship appointment was taking approximately 150 days. The majority of these patients needed, among other things, someone to complete their Medicaid applications to enter a custodial care home. The Care Management Department had been using the Department of Human Services as a conduit for these patients. Unfortunately, DHS was short staffed and had tremendous caseloads.

We put together a team that included social workers, in house legal counsel, and a Nursing Home Coordinator who had the best practice for length of time to obtain guardianship. Learning from her experiences, we redefined the Hospital’s tools and processes. This included templates, checklists, and a process to have counsel go directly to the courts to request the appointment of a guardian. The result: we were able to reduce the process to an average of 30 days. The savings of 120 days with a net cost of $645 per day allowed the hospital to avoid $77,400 of expense and fill the resulting bed days This allowed patients to move to an appropriate level of care sooner, and freed up much needed medical/surgical beds for the hospital.

These are just a few examples of how we can make small changes in our practices that lead to big benefits for our patients and their families. I believe that we should acknowledge and celebrate these wins as we do the larger changes.

By Wanda Pell, Director, Novia Strategies

1 Augistine MD, James J. “The True Cost of Ambulance Diversion”. Emergency Physicians Monthly. 11/24/2013

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